Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

PR REMOVE DEEP SHOULDER FOREIGN BODY

Professional

Both

$1,039.00

Service Code	HCPCS 23331
Min. Negotiated Rate	$415.60
Max. Negotiated Rate	$675.35
Rate for Payer: Aetna Medicare	$519.50
Rate for Payer: BCBS Complete	$415.60
Rate for Payer: Cash Price	$831.20
Rate for Payer: Priority Health Cigna Priority Health	$675.35

PR REMOVE INT DWELL URETERAL STENT TRANSURETHRAL

Professional

Both

$1,582.00

Service Code	HCPCS 50386
Min. Negotiated Rate	$103.09
Max. Negotiated Rate	$1,103.43
Rate for Payer: Aetna Commercial	$206.76
Rate for Payer: Aetna Medicare	$791.00
Rate for Payer: BCBS Complete	$108.24
Rate for Payer: BCN Commercial	$1,103.43
Rate for Payer: Cash Price	$1,265.60
Rate for Payer: Cash Price	$1,265.60
Rate for Payer: Meridian Medicaid	$108.24
Rate for Payer: Priority Health Choice Medicaid	$103.09
Rate for Payer: Priority Health Cigna Priority Health	$1,028.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$255.12
Rate for Payer: Priority Health Narrow Network	$255.12
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$216.17
Rate for Payer: UHC Exchange	$216.17
Rate for Payer: UHCCP Medicaid	$103.09

PR REMOVE NAIL BED/FINGER TIP

Professional

Both

$530.00

Service Code	HCPCS 11752
Min. Negotiated Rate	$212.00
Max. Negotiated Rate	$344.50
Rate for Payer: Aetna Medicare	$265.00
Rate for Payer: BCBS Complete	$212.00
Rate for Payer: Cash Price	$424.00
Rate for Payer: Priority Health Cigna Priority Health	$344.50

PR REMOVE & REPLACE INDWELL URETERAL STENT TRURTHRL

Professional

Both

$2,093.00

Service Code	HCPCS 50385
Min. Negotiated Rate	$136.11
Max. Negotiated Rate	$2,060.90
Rate for Payer: Aetna Commercial	$279.88
Rate for Payer: Aetna Medicare	$1,046.50
Rate for Payer: BCBS Complete	$142.92
Rate for Payer: BCBS Trust/PPO	$2,060.90
Rate for Payer: BCN Commercial	$1,491.44
Rate for Payer: Cash Price	$1,674.40
Rate for Payer: Cash Price	$1,674.40
Rate for Payer: Meridian Medicaid	$142.92
Rate for Payer: Priority Health Choice Medicaid	$136.11
Rate for Payer: Priority Health Cigna Priority Health	$1,360.45
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$336.06
Rate for Payer: Priority Health Narrow Network	$336.06
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$286.13
Rate for Payer: UHC Exchange	$286.13
Rate for Payer: UHCCP Medicaid	$136.11

PR REMVL INFLATABLE URETHRAL/BLADDER NECK SPHINCTER

Professional

Both

$1,924.00

Service Code	HCPCS 53446
Min. Negotiated Rate	$413.01
Max. Negotiated Rate	$1,250.60
Rate for Payer: Aetna Commercial	$823.67
Rate for Payer: Aetna Medicare	$962.00
Rate for Payer: BCBS Complete	$433.66
Rate for Payer: BCBS Trust/PPO	$437.96
Rate for Payer: BCN Commercial	$928.00
Rate for Payer: Cash Price	$1,539.20
Rate for Payer: Cash Price	$1,539.20
Rate for Payer: Meridian Medicaid	$433.66
Rate for Payer: Priority Health Choice Medicaid	$413.01
Rate for Payer: Priority Health Cigna Priority Health	$1,250.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,025.79
Rate for Payer: Priority Health Narrow Network	$1,025.79
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$774.48
Rate for Payer: UHC Exchange	$774.48
Rate for Payer: UHCCP Medicaid	$413.01

PR REMVL PERM PM PLSE GEN W/REPL PLSE GEN SNGL LEAD

Professional

Both

$702.00

Service Code	HCPCS 33227
Min. Negotiated Rate	$214.07
Max. Negotiated Rate	$1,104.68
Rate for Payer: Aetna Commercial	$454.03
Rate for Payer: Aetna Medicare	$351.00
Rate for Payer: BCBS Complete	$224.77
Rate for Payer: BCBS Trust/PPO	$1,104.68
Rate for Payer: BCN Commercial	$490.63
Rate for Payer: Cash Price	$561.60
Rate for Payer: Cash Price	$561.60
Rate for Payer: Meridian Medicaid	$224.77
Rate for Payer: Priority Health Choice Medicaid	$214.07
Rate for Payer: Priority Health Cigna Priority Health	$456.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$533.41
Rate for Payer: Priority Health Narrow Network	$533.41
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$461.66
Rate for Payer: UHC Exchange	$461.66
Rate for Payer: UHCCP Medicaid	$214.07

PR REMVL PERM PM PLS GEN W/REPL PLSE GEN 2 LEAD SYS

Professional

Both

$727.00

Service Code	HCPCS 33228
Min. Negotiated Rate	$224.08
Max. Negotiated Rate	$864.30
Rate for Payer: Aetna Commercial	$475.59
Rate for Payer: Aetna Medicare	$363.50
Rate for Payer: BCBS Complete	$235.28
Rate for Payer: BCBS Trust/PPO	$864.30
Rate for Payer: BCN Commercial	$512.14
Rate for Payer: Cash Price	$581.60
Rate for Payer: Cash Price	$581.60
Rate for Payer: Meridian Medicaid	$235.28
Rate for Payer: Priority Health Choice Medicaid	$224.08
Rate for Payer: Priority Health Cigna Priority Health	$472.55
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$556.82
Rate for Payer: Priority Health Narrow Network	$556.82
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$481.54
Rate for Payer: UHC Exchange	$481.54
Rate for Payer: UHCCP Medicaid	$224.08

PR REMVL PERM PM PLS GEN W/REPL PLSE GEN MULT LEAD

Professional

Both

$578.00

Service Code	HCPCS 33229
Min. Negotiated Rate	$234.94
Max. Negotiated Rate	$1,010.11
Rate for Payer: Aetna Commercial	$502.63
Rate for Payer: Aetna Medicare	$289.00
Rate for Payer: BCBS Complete	$246.69
Rate for Payer: BCBS Trust/PPO	$1,010.11
Rate for Payer: BCN Commercial	$541.46
Rate for Payer: Cash Price	$462.40
Rate for Payer: Cash Price	$462.40
Rate for Payer: Meridian Medicaid	$246.69
Rate for Payer: Priority Health Choice Medicaid	$234.94
Rate for Payer: Priority Health Cigna Priority Health	$375.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$585.55
Rate for Payer: Priority Health Narrow Network	$585.55
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$501.41
Rate for Payer: UHC Exchange	$501.41
Rate for Payer: UHCCP Medicaid	$234.94

PR REMV TISSUE FOR GRAFT OTHR

Professional

Both

$819.00

Service Code	HCPCS 20926
Min. Negotiated Rate	$327.60
Max. Negotiated Rate	$532.35
Rate for Payer: Aetna Medicare	$409.50
Rate for Payer: BCBS Complete	$327.60
Rate for Payer: Cash Price	$655.20
Rate for Payer: Priority Health Cigna Priority Health	$532.35

PR RENAL ANGIO, CARDIAC CATH

Professional

Both

$36.00

Service Code	HCPCS G0275
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 RENAL BIOPSY PRQ TROCAR/NEEDLE

Professional

Both

$1,053.00

Service Code	HCPCS 50200
Min. Negotiated Rate	$79.66
Max. Negotiated Rate	$760.38
Rate for Payer: Aetna Commercial	$162.74
Rate for Payer: Aetna Medicare	$526.50
Rate for Payer: BCBS Complete	$83.64
Rate for Payer: BCN Commercial	$760.38
Rate for Payer: Cash Price	$842.40
Rate for Payer: Cash Price	$842.40
Rate for Payer: Meridian Medicaid	$83.64
Rate for Payer: Priority Health Choice Medicaid	$79.66
Rate for Payer: Priority Health Cigna Priority Health	$684.45
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$198.13
Rate for Payer: Priority Health Narrow Network	$198.13
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$172.67
Rate for Payer: UHC Exchange	$172.67
Rate for Payer: UHCCP Medicaid	$79.66

PR RENAL BIOPSY SURG EXPOSURE KIDNEY

Professional

Both

$1,699.00

Service Code	HCPCS 50205
Min. Negotiated Rate	$486.71
Max. Negotiated Rate	$2,575.99
Rate for Payer: Aetna Commercial	$974.57
Rate for Payer: Aetna Medicare	$849.50
Rate for Payer: BCBS Complete	$511.05
Rate for Payer: BCBS Trust/PPO	$2,575.99
Rate for Payer: BCN Commercial	$1,101.48
Rate for Payer: Cash Price	$1,359.20
Rate for Payer: Cash Price	$1,359.20
Rate for Payer: Meridian Medicaid	$511.05
Rate for Payer: Priority Health Choice Medicaid	$486.71
Rate for Payer: Priority Health Cigna Priority Health	$1,104.35
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,209.54
Rate for Payer: Priority Health Narrow Network	$1,209.54
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$841.01
Rate for Payer: UHC Exchange	$841.01
Rate for Payer: UHCCP Medicaid	$486.71

PR RENAL ENDOSCOPY NEPHROSTOMY W/WO IRRIGATION

Professional

Both

$726.00

Service Code	HCPCS 50551
Min. Negotiated Rate	$185.74
Max. Negotiated Rate	$3,748.82
Rate for Payer: Aetna Commercial	$376.62
Rate for Payer: Aetna Medicare	$363.00
Rate for Payer: BCBS Complete	$195.03
Rate for Payer: BCBS Trust/PPO	$3,748.82
Rate for Payer: BCN Commercial	$522.88
Rate for Payer: Cash Price	$580.80
Rate for Payer: Cash Price	$580.80
Rate for Payer: Meridian Medicaid	$195.03
Rate for Payer: Priority Health Choice Medicaid	$185.74
Rate for Payer: Priority Health Cigna Priority Health	$471.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$461.23
Rate for Payer: Priority Health Narrow Network	$461.23
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$359.43
Rate for Payer: UHC Exchange	$359.43
Rate for Payer: UHCCP Medicaid	$185.74

PR RENAL EXPLORATION NOT NECESSITATING OTH SPEC PX

Professional

Both

$2,514.00

Service Code	HCPCS 50010
Min. Negotiated Rate	$452.20
Max. Negotiated Rate	$3,137.57
Rate for Payer: Aetna Commercial	$951.04
Rate for Payer: Aetna Medicare	$1,257.00
Rate for Payer: BCBS Complete	$474.81
Rate for Payer: BCBS Trust/PPO	$3,137.57
Rate for Payer: BCN Commercial	$1,082.91
Rate for Payer: Cash Price	$2,011.20
Rate for Payer: Cash Price	$2,011.20
Rate for Payer: Meridian Medicaid	$474.81
Rate for Payer: Priority Health Choice Medicaid	$452.20
Rate for Payer: Priority Health Cigna Priority Health	$1,634.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,124.32
Rate for Payer: Priority Health Narrow Network	$1,124.32
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$851.79
Rate for Payer: UHC Exchange	$851.79
Rate for Payer: UHCCP Medicaid	$452.20

PR RENAL NDSC NEPHROS/PYELOSTOMY BIOPSY

Professional

Both

$784.00

Service Code	HCPCS 50555
Min. Negotiated Rate	$215.77
Max. Negotiated Rate	$4,030.40
Rate for Payer: Aetna Commercial	$436.06
Rate for Payer: Aetna Medicare	$392.00
Rate for Payer: BCBS Complete	$226.56
Rate for Payer: BCBS Trust/PPO	$4,030.40
Rate for Payer: BCN Commercial	$595.70
Rate for Payer: Cash Price	$627.20
Rate for Payer: Cash Price	$627.20
Rate for Payer: Meridian Medicaid	$226.56
Rate for Payer: Priority Health Choice Medicaid	$215.77
Rate for Payer: Priority Health Cigna Priority Health	$509.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$535.26
Rate for Payer: Priority Health Narrow Network	$535.26
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$415.48
Rate for Payer: UHC Exchange	$415.48
Rate for Payer: UHCCP Medicaid	$215.77

PR RENAL NDSC NEPHROS/PYELOSTOMY FULG&/INC W/WO BI

Professional

Both

$831.00

Service Code	HCPCS 50557
Min. Negotiated Rate	$218.33
Max. Negotiated Rate	$4,171.46
Rate for Payer: Aetna Commercial	$442.24
Rate for Payer: Aetna Medicare	$415.50
Rate for Payer: BCBS Complete	$229.25
Rate for Payer: BCBS Trust/PPO	$4,171.46
Rate for Payer: BCN Commercial	$606.45
Rate for Payer: Cash Price	$664.80
Rate for Payer: Cash Price	$664.80
Rate for Payer: Meridian Medicaid	$229.25
Rate for Payer: Priority Health Choice Medicaid	$218.33
Rate for Payer: Priority Health Cigna Priority Health	$540.15
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$542.19
Rate for Payer: Priority Health Narrow Network	$542.19
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$421.81
Rate for Payer: UHC Exchange	$421.81
Rate for Payer: UHCCP Medicaid	$218.33

PR RENAL NDSC NEPHROS/PYELOSTOMY RMVL FB/CALCULUS

Professional

Both

$908.00

Service Code	HCPCS 50561
Min. Negotiated Rate	$248.78
Max. Negotiated Rate	$687.57
Rate for Payer: Aetna Commercial	$505.20
Rate for Payer: Aetna Medicare	$454.00
Rate for Payer: BCBS Complete	$261.22
Rate for Payer: BCBS Trust/PPO	$287.92
Rate for Payer: BCN Commercial	$687.57
Rate for Payer: Cash Price	$726.40
Rate for Payer: Cash Price	$726.40
Rate for Payer: Meridian Medicaid	$261.22
Rate for Payer: Priority Health Choice Medicaid	$248.78
Rate for Payer: Priority Health Cigna Priority Health	$590.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$619.41
Rate for Payer: Priority Health Narrow Network	$619.41
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$482.52
Rate for Payer: UHC Exchange	$482.52
Rate for Payer: UHCCP Medicaid	$248.78

PR RENAL NDSC NEPHROST W/URETERAL CATH W/WO DILA

Professional

Both

$726.00

Service Code	HCPCS 50553
Min. Negotiated Rate	$198.30
Max. Negotiated Rate	$3,834.93
Rate for Payer: Aetna Commercial	$402.76
Rate for Payer: Aetna Medicare	$363.00
Rate for Payer: BCBS Complete	$208.22
Rate for Payer: BCBS Trust/PPO	$3,834.93
Rate for Payer: BCN Commercial	$560.51
Rate for Payer: Cash Price	$580.80
Rate for Payer: Cash Price	$580.80
Rate for Payer: Meridian Medicaid	$208.22
Rate for Payer: Priority Health Choice Medicaid	$198.30
Rate for Payer: Priority Health Cigna Priority Health	$471.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$493.18
Rate for Payer: Priority Health Narrow Network	$493.18
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$382.90
Rate for Payer: UHC Exchange	$382.90
Rate for Payer: UHCCP Medicaid	$198.30

PR RENAL NDSC NEPHROTOMY W/WO IRRIGATION

Professional

Both

$954.00

Service Code	HCPCS 50570
Min. Negotiated Rate	$309.70
Max. Negotiated Rate	$770.67
Rate for Payer: Aetna Commercial	$629.91
Rate for Payer: Aetna Medicare	$477.00
Rate for Payer: BCBS Complete	$325.18
Rate for Payer: BCBS Trust/PPO	$634.49
Rate for Payer: BCN Commercial	$699.30
Rate for Payer: Cash Price	$763.20
Rate for Payer: Cash Price	$763.20
Rate for Payer: Meridian Medicaid	$325.18
Rate for Payer: Priority Health Choice Medicaid	$309.70
Rate for Payer: Priority Health Cigna Priority Health	$620.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$770.67
Rate for Payer: Priority Health Narrow Network	$770.67
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$601.31
Rate for Payer: UHC Exchange	$601.31
Rate for Payer: UHCCP Medicaid	$309.70

PR REOPENING RECENT LAPAROTOMY

Professional

Both

$2,127.00

Service Code	HCPCS 49002
Min. Negotiated Rate	$611.24
Max. Negotiated Rate	$1,863.76
Rate for Payer: Aetna Commercial	$1,409.38
Rate for Payer: Aetna Medicare	$1,063.50
Rate for Payer: BCBS Complete	$702.71
Rate for Payer: BCBS Trust/PPO	$611.24
Rate for Payer: BCN Commercial	$1,518.81
Rate for Payer: Cash Price	$1,701.60
Rate for Payer: Cash Price	$1,701.60
Rate for Payer: Meridian Medicaid	$702.71
Rate for Payer: Priority Health Choice Medicaid	$669.25
Rate for Payer: Priority Health Cigna Priority Health	$1,382.55
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,863.76
Rate for Payer: Priority Health Narrow Network	$1,863.76
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,253.69
Rate for Payer: UHC Exchange	$1,253.69
Rate for Payer: UHCCP Medicaid	$669.25

PR REPAIR ANAL FISTULA W/FIBRIN GLUE

Professional

Both

$341.00

Service Code	HCPCS 46706
Min. Negotiated Rate	$117.58
Max. Negotiated Rate	$325.15
Rate for Payer: Aetna Commercial	$238.77
Rate for Payer: Aetna Medicare	$170.50
Rate for Payer: BCBS Complete	$123.46
Rate for Payer: BCBS Trust/PPO	$169.58
Rate for Payer: BCN Commercial	$262.91
Rate for Payer: Cash Price	$272.80
Rate for Payer: Cash Price	$272.80
Rate for Payer: Meridian Medicaid	$123.46
Rate for Payer: Priority Health Choice Medicaid	$117.58
Rate for Payer: Priority Health Cigna Priority Health	$221.65
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$325.15
Rate for Payer: Priority Health Narrow Network	$325.15
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$197.55
Rate for Payer: UHC Exchange	$197.55
Rate for Payer: UHCCP Medicaid	$117.58

PR REPAIR ANORECTAL FISTULA PLUG

Professional

Both

$1,037.00

Service Code	HCPCS 46707
Min. Negotiated Rate	$192.83
Max. Negotiated Rate	$910.41
Rate for Payer: Aetna Commercial	$673.80
Rate for Payer: Aetna Medicare	$518.50
Rate for Payer: BCBS Complete	$345.31
Rate for Payer: BCBS Trust/PPO	$192.83
Rate for Payer: BCN Commercial	$741.32
Rate for Payer: Cash Price	$829.60
Rate for Payer: Cash Price	$829.60
Rate for Payer: Meridian Medicaid	$345.31
Rate for Payer: Priority Health Choice Medicaid	$328.87
Rate for Payer: Priority Health Cigna Priority Health	$674.05
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$910.41
Rate for Payer: Priority Health Narrow Network	$910.41
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$560.70
Rate for Payer: UHC Exchange	$560.70
Rate for Payer: UHCCP Medicaid	$328.87

PR REPAIR BIFID EARLOBES - BILATERAL

Professional

Both

$1,020.00

Service Code	HCPCS 00535
Hospital Revenue Code	990
Min. Negotiated Rate	$408.00
Max. Negotiated Rate	$663.00
Rate for Payer: Aetna Medicare	$510.00
Rate for Payer: BCBS Complete	$408.00
Rate for Payer: Cash Price	$816.00
Rate for Payer: Priority Health Cigna Priority Health	$663.00

PR REPAIR BIFID EARLOBES - UNILATERAL

Professional

Both

$612.00

Service Code	HCPCS 00534
Hospital Revenue Code	990
Min. Negotiated Rate	$244.80
Max. Negotiated Rate	$397.80
Rate for Payer: Aetna Medicare	$306.00
Rate for Payer: BCBS Complete	$244.80
Rate for Payer: Cash Price	$489.60
Rate for Payer: Priority Health Cigna Priority Health	$397.80

PR REPAIR BLOOD VESSEL DIRECT HAND FINGER

Professional

Both

$1,353.00

Service Code	HCPCS 35207
Min. Negotiated Rate	$292.68
Max. Negotiated Rate	$1,209.90
Rate for Payer: Aetna Commercial	$1,002.58
Rate for Payer: Aetna Medicare	$676.50
Rate for Payer: BCBS Complete	$514.17
Rate for Payer: BCBS Trust/PPO	$292.68
Rate for Payer: BCN Commercial	$1,109.79
Rate for Payer: Cash Price	$1,082.40
Rate for Payer: Cash Price	$1,082.40
Rate for Payer: Meridian Medicaid	$514.17
Rate for Payer: Priority Health Choice Medicaid	$489.69
Rate for Payer: Priority Health Cigna Priority Health	$879.45
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,209.90
Rate for Payer: Priority Health Narrow Network	$1,209.90
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$901.90
Rate for Payer: UHC Exchange	$901.90
Rate for Payer: UHCCP Medicaid	$489.69

Know your out-of-pocket cost for care.

All Charges