Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

PR RPR TENDON XTNSR FOOT SEC W/FREE GRAFT EA TENDON

Professional

Both

$947.00

Service Code	HCPCS 28210
Min. Negotiated Rate	$273.07
Max. Negotiated Rate	$912.90
Rate for Payer: Aetna Commercial	$564.04
Rate for Payer: Aetna Medicare	$473.50
Rate for Payer: BCBS Complete	$286.72
Rate for Payer: BCBS Trust/PPO	$912.90
Rate for Payer: BCN Commercial	$867.89
Rate for Payer: Cash Price	$757.60
Rate for Payer: Cash Price	$757.60
Rate for Payer: Meridian Medicaid	$286.72
Rate for Payer: Priority Health Choice Medicaid	$273.07
Rate for Payer: Priority Health Cigna Priority Health	$615.55
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$653.37
Rate for Payer: Priority Health Narrow Network	$653.37
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$482.56
Rate for Payer: UHC Exchange	$482.56
Rate for Payer: UHCCP Medicaid	$273.07

PR RPR THORACOABDOMINAL AORTIC ANEURYS W/WO BYPASS

Professional

Both

$8,690.00

Service Code	HCPCS 33877
Min. Negotiated Rate	$2,114.78
Max. Negotiated Rate	$5,648.50
Rate for Payer: Aetna Commercial	$4,855.61
Rate for Payer: Aetna Medicare	$4,345.00
Rate for Payer: BCBS Complete	$2,367.78
Rate for Payer: BCBS Trust/PPO	$2,114.78
Rate for Payer: BCN Commercial	$5,146.27
Rate for Payer: Cash Price	$6,952.00
Rate for Payer: Cash Price	$6,952.00
Rate for Payer: Meridian Medicaid	$2,367.78
Rate for Payer: Priority Health Choice Medicaid	$2,255.03
Rate for Payer: Priority Health Cigna Priority Health	$5,648.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$5,617.67
Rate for Payer: Priority Health Narrow Network	$5,617.67
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$4,755.75
Rate for Payer: UHC Exchange	$4,755.75
Rate for Payer: UHCCP Medicaid	$2,255.03

PR RPR TUNICA VAGINALIS HYDROCELE BOTTLE TYPE

Professional

Both

$630.00

Service Code	HCPCS 55060
Min. Negotiated Rate	$245.38
Max. Negotiated Rate	$1,220.90
Rate for Payer: Aetna Commercial	$486.63
Rate for Payer: Aetna Medicare	$315.00
Rate for Payer: BCBS Complete	$257.65
Rate for Payer: BCBS Trust/PPO	$1,220.90
Rate for Payer: BCN Commercial	$551.23
Rate for Payer: Cash Price	$504.00
Rate for Payer: Cash Price	$504.00
Rate for Payer: Meridian Medicaid	$257.65
Rate for Payer: Priority Health Choice Medicaid	$245.38
Rate for Payer: Priority Health Cigna Priority Health	$409.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$609.30
Rate for Payer: Priority Health Narrow Network	$609.30
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$452.99
Rate for Payer: UHC Exchange	$452.99
Rate for Payer: UHCCP Medicaid	$245.38

PR RPR TUN/NON-TUN CTR VAD CATH W/O SUBQ PORT/PMP

Professional

Both

$448.00

Service Code	HCPCS 36575
Min. Negotiated Rate	$21.09
Max. Negotiated Rate	$1,177.58
Rate for Payer: Aetna Commercial	$46.01
Rate for Payer: Aetna Medicare	$224.00
Rate for Payer: BCBS Complete	$22.14
Rate for Payer: BCBS Trust/PPO	$1,177.58
Rate for Payer: BCN Commercial	$212.57
Rate for Payer: Cash Price	$358.40
Rate for Payer: Cash Price	$358.40
Rate for Payer: Meridian Medicaid	$22.14
Rate for Payer: Priority Health Choice Medicaid	$21.09
Rate for Payer: Priority Health Cigna Priority Health	$291.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$52.12
Rate for Payer: Priority Health Narrow Network	$52.12
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$45.46
Rate for Payer: UHC Exchange	$45.46
Rate for Payer: UHCCP Medicaid	$21.09

PR RPR UMBILICAL HERNIA < 5 YRS INCARCERATED

Professional

Both

$1,463.00

Service Code	HCPCS 49582
Min. Negotiated Rate	$585.20
Max. Negotiated Rate	$950.95
Rate for Payer: Aetna Medicare	$731.50
Rate for Payer: BCBS Complete	$585.20
Rate for Payer: Cash Price	$1,170.40
Rate for Payer: Priority Health Cigna Priority Health	$950.95

PR RPR UMBILICAL HERNIA < 5 YRS REDUCIBLE

Professional

Both

$1,268.00

Service Code	HCPCS 49580
Min. Negotiated Rate	$507.20
Max. Negotiated Rate	$824.20
Rate for Payer: Aetna Medicare	$634.00
Rate for Payer: BCBS Complete	$507.20
Rate for Payer: Cash Price	$1,014.40
Rate for Payer: Priority Health Cigna Priority Health	$824.20

PR RPR UMBILICAL HERNIA AGE 5 YRS/> INCARCERATED

Professional

Both

$1,685.00

Service Code	HCPCS 49587
Min. Negotiated Rate	$674.00
Max. Negotiated Rate	$1,095.25
Rate for Payer: Aetna Medicare	$842.50
Rate for Payer: BCBS Complete	$674.00
Rate for Payer: Cash Price	$1,348.00
Rate for Payer: Priority Health Cigna Priority Health	$1,095.25

PR RPR UMBILICAL HRNA 5 YRS/> REDUCIBLE

Professional

Both

$1,463.00

Service Code	HCPCS 49585
Min. Negotiated Rate	$585.20
Max. Negotiated Rate	$950.95
Rate for Payer: Aetna Medicare	$731.50
Rate for Payer: BCBS Complete	$585.20
Rate for Payer: Cash Price	$1,170.40
Rate for Payer: Priority Health Cigna Priority Health	$950.95

PR RPR VENTR O/F TRC OBSTRCJ PATCH ENLGMENT O/F TRC

Professional

Both

$8,041.00

Service Code	HCPCS 33414
Min. Negotiated Rate	$509.28
Max. Negotiated Rate	$5,226.65
Rate for Payer: Aetna Commercial	$2,886.79
Rate for Payer: Aetna Medicare	$4,020.50
Rate for Payer: BCBS Complete	$1,416.83
Rate for Payer: BCBS Trust/PPO	$509.28
Rate for Payer: BCN Commercial	$3,076.23
Rate for Payer: Cash Price	$6,432.80
Rate for Payer: Cash Price	$6,432.80
Rate for Payer: Meridian Medicaid	$1,416.83
Rate for Payer: Priority Health Choice Medicaid	$1,349.36
Rate for Payer: Priority Health Cigna Priority Health	$5,226.65
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$3,361.66
Rate for Payer: Priority Health Narrow Network	$3,361.66
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$2,859.23
Rate for Payer: UHC Exchange	$2,859.23
Rate for Payer: UHCCP Medicaid	$1,349.36

PR RPR XTNSR TDN CNTRL SLIP SEC W/FR GRFT EA FINGER

Professional

Both

$2,823.00

Service Code	HCPCS 26428
Min. Negotiated Rate	$98.26
Max. Negotiated Rate	$1,834.95
Rate for Payer: Aetna Commercial	$1,057.07
Rate for Payer: Aetna Medicare	$1,411.50
Rate for Payer: BCBS Complete	$539.22
Rate for Payer: BCBS Trust/PPO	$98.26
Rate for Payer: BCN Commercial	$1,186.02
Rate for Payer: Cash Price	$2,258.40
Rate for Payer: Cash Price	$2,258.40
Rate for Payer: Meridian Medicaid	$539.22
Rate for Payer: Priority Health Choice Medicaid	$513.54
Rate for Payer: Priority Health Cigna Priority Health	$1,834.95
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,232.46
Rate for Payer: Priority Health Narrow Network	$1,232.46
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$832.09
Rate for Payer: UHC Exchange	$832.09
Rate for Payer: UHCCP Medicaid	$513.54

PR RPR XTNSR TDN CNTRL SLIP TISS W/LAT BAND EA FNGR

Professional

Both

$1,983.00

Service Code	HCPCS 26426
Min. Negotiated Rate	$195.47
Max. Negotiated Rate	$1,288.95
Rate for Payer: Aetna Commercial	$669.62
Rate for Payer: Aetna Medicare	$991.50
Rate for Payer: BCBS Complete	$349.11
Rate for Payer: BCBS Trust/PPO	$195.47
Rate for Payer: BCN Commercial	$747.19
Rate for Payer: Cash Price	$1,586.40
Rate for Payer: Cash Price	$1,586.40
Rate for Payer: Meridian Medicaid	$349.11
Rate for Payer: Priority Health Choice Medicaid	$332.49
Rate for Payer: Priority Health Cigna Priority Health	$1,288.95
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$786.19
Rate for Payer: Priority Health Narrow Network	$786.19
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$621.26
Rate for Payer: UHC Exchange	$621.26
Rate for Payer: UHCCP Medicaid	$332.49

PR RPSG PREV IMPLTED CAR VEN SYS L VENTR ELTRD

Professional

Both

$1,297.00

Service Code	HCPCS 33226
Min. Negotiated Rate	$306.72
Max. Negotiated Rate	$1,099.92
Rate for Payer: Aetna Commercial	$663.10
Rate for Payer: Aetna Medicare	$648.50
Rate for Payer: BCBS Complete	$322.06
Rate for Payer: BCBS Trust/PPO	$1,099.92
Rate for Payer: BCN Commercial	$702.72
Rate for Payer: Cash Price	$1,037.60
Rate for Payer: Cash Price	$1,037.60
Rate for Payer: Meridian Medicaid	$322.06
Rate for Payer: Priority Health Choice Medicaid	$306.72
Rate for Payer: Priority Health Cigna Priority Health	$843.05
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$763.18
Rate for Payer: Priority Health Narrow Network	$763.18
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$660.18
Rate for Payer: UHC Exchange	$660.18
Rate for Payer: UHCCP Medicaid	$306.72

PR RPSG PREV IMPLTED PM/DFB R ATR/R VENTR ELECTRODE

Professional

Both

$1,029.00

Service Code	HCPCS 33215
Min. Negotiated Rate	$196.17
Max. Negotiated Rate	$1,453.88
Rate for Payer: Aetna Commercial	$415.09
Rate for Payer: Aetna Medicare	$514.50
Rate for Payer: BCBS Complete	$205.98
Rate for Payer: BCBS Trust/PPO	$1,453.88
Rate for Payer: BCN Commercial	$448.61
Rate for Payer: Cash Price	$823.20
Rate for Payer: Cash Price	$823.20
Rate for Payer: Meridian Medicaid	$205.98
Rate for Payer: Priority Health Choice Medicaid	$196.17
Rate for Payer: Priority Health Cigna Priority Health	$668.85
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$487.69
Rate for Payer: Priority Health Narrow Network	$487.69
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$408.54
Rate for Payer: UHC Exchange	$408.54
Rate for Payer: UHCCP Medicaid	$196.17

PR RPSG PREVIOUSLY PLACED CVC UNDER FLUOR GDNCE

Professional

Both

$316.00

Service Code	HCPCS 36597
Min. Negotiated Rate	$37.91
Max. Negotiated Rate	$578.49
Rate for Payer: Aetna Commercial	$81.05
Rate for Payer: Aetna Medicare	$158.00
Rate for Payer: BCBS Complete	$39.81
Rate for Payer: BCBS Trust/PPO	$578.49
Rate for Payer: BCN Commercial	$163.71
Rate for Payer: Cash Price	$252.80
Rate for Payer: Cash Price	$252.80
Rate for Payer: Meridian Medicaid	$39.81
Rate for Payer: Priority Health Choice Medicaid	$37.91
Rate for Payer: Priority Health Cigna Priority Health	$205.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$93.61
Rate for Payer: Priority Health Narrow Network	$93.61
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$80.60
Rate for Payer: UHC Exchange	$80.60
Rate for Payer: UHCCP Medicaid	$37.91

PR RSV MONOCLONAL ANTB SEASONAL DOSE 0.5ML IM USE

Professional

Both

$1,303.00

Service Code	HCPCS 90380
Min. Negotiated Rate	$504.90
Max. Negotiated Rate	$846.95
Rate for Payer: Aetna Commercial	$504.90
Rate for Payer: Aetna Medicare	$651.50
Rate for Payer: BCBS Complete	$521.20
Rate for Payer: BCBS Trust/PPO	$504.90
Rate for Payer: Cash Price	$1,042.40
Rate for Payer: Cash Price	$1,042.40
Rate for Payer: Priority Health Cigna Priority Health	$846.95
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$623.70
Rate for Payer: UHC Exchange	$623.70

PR RSV MONOCLONAL ANTB SEASONAL DOSE 1 ML IM USE

Professional

Both

$1,303.00

Service Code	HCPCS 90381
Min. Negotiated Rate	$504.90
Max. Negotiated Rate	$846.95
Rate for Payer: Aetna Commercial	$504.90
Rate for Payer: Aetna Medicare	$651.50
Rate for Payer: BCBS Complete	$521.20
Rate for Payer: BCBS Trust/PPO	$504.90
Rate for Payer: Cash Price	$1,042.40
Rate for Payer: Cash Price	$1,042.40
Rate for Payer: Priority Health Cigna Priority Health	$846.95
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$623.70
Rate for Payer: UHC Exchange	$623.70

PR RSV VACCINE PREF SUBUNIT BIVALENT FOR IM USE

Professional

Both

$840.00

Service Code	HCPCS 90678
Min. Negotiated Rate	$300.90
Max. Negotiated Rate	$546.00
Rate for Payer: Aetna Commercial	$300.90
Rate for Payer: Aetna Medicare	$420.00
Rate for Payer: BCBS Complete	$336.00
Rate for Payer: BCBS Trust/PPO	$347.00
Rate for Payer: Cash Price	$672.00
Rate for Payer: Cash Price	$672.00
Rate for Payer: Priority Health Cigna Priority Health	$546.00
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$354.00
Rate for Payer: UHC Exchange	$354.00

PR RSV VACC PREF RECOMBINANT ADJUVANTED FOR IM USE

Professional

Both

$797.00

Service Code	HCPCS 90679
Min. Negotiated Rate	$285.60
Max. Negotiated Rate	$518.05
Rate for Payer: Aetna Commercial	$285.60
Rate for Payer: Aetna Medicare	$398.50
Rate for Payer: BCBS Complete	$318.80
Rate for Payer: BCBS Trust/PPO	$285.60
Rate for Payer: Cash Price	$637.60
Rate for Payer: Cash Price	$637.60
Rate for Payer: Priority Health Cigna Priority Health	$518.05
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$336.00
Rate for Payer: UHC Exchange	$336.00

PR RTRVL INTRVAS VC FILTR W/WO ACS VSL SELXN RS&I

Professional

Both

$2,946.00

Service Code	HCPCS 37193
Min. Negotiated Rate	$215.98
Max. Negotiated Rate	$2,206.87
Rate for Payer: Aetna Commercial	$464.98
Rate for Payer: Aetna Medicare	$1,473.00
Rate for Payer: BCBS Complete	$226.78
Rate for Payer: BCBS Trust/PPO	$524.07
Rate for Payer: BCN Commercial	$2,206.87
Rate for Payer: Cash Price	$2,356.80
Rate for Payer: Cash Price	$2,356.80
Rate for Payer: Meridian Medicaid	$226.78
Rate for Payer: Priority Health Choice Medicaid	$215.98
Rate for Payer: Priority Health Cigna Priority Health	$1,914.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$536.61
Rate for Payer: Priority Health Narrow Network	$536.61
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$504.41
Rate for Payer: UHC Exchange	$504.41
Rate for Payer: UHCCP Medicaid	$215.98

PR RUBELLA IMMUNIZATION, SUBCUT

Professional

Both

$31.00

Service Code	HCPCS 90706
Min. Negotiated Rate	$12.40
Max. Negotiated Rate	$20.15
Rate for Payer: Aetna Medicare	$15.50
Rate for Payer: BCBS Complete	$12.40
Rate for Payer: Cash Price	$24.80
Rate for Payer: Priority Health Cigna Priority Health	$20.15

PR RV1 VACCINE 2 DOSE SCHEDULE LIVE FOR ORAL USE

Professional

Both

$159.00

Service Code	HCPCS 90681
Min. Negotiated Rate	$63.60
Max. Negotiated Rate	$166.49
Rate for Payer: Aetna Commercial	$137.29
Rate for Payer: Aetna Medicare	$79.50
Rate for Payer: BCBS Complete	$63.60
Rate for Payer: BCBS Trust/PPO	$129.14
Rate for Payer: BCN Commercial	$129.14
Rate for Payer: Cash Price	$127.20
Rate for Payer: Cash Price	$127.20
Rate for Payer: Priority Health Cigna Priority Health	$103.35
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$166.49
Rate for Payer: UHC Exchange	$166.49

PR RV5 VACCINE 3 DOSE SCHEDULE LIVE FOR ORAL USE

Professional

Both

$96.00

Service Code	HCPCS 90680
Min. Negotiated Rate	$38.40
Max. Negotiated Rate	$118.58
Rate for Payer: Aetna Commercial	$97.75
Rate for Payer: Aetna Medicare	$48.00
Rate for Payer: BCBS Complete	$38.40
Rate for Payer: BCBS Trust/PPO	$91.96
Rate for Payer: BCN Commercial	$91.96
Rate for Payer: Cash Price	$76.80
Rate for Payer: Cash Price	$76.80
Rate for Payer: Priority Health Cigna Priority Health	$62.40
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$118.58
Rate for Payer: UHC Exchange	$118.58

PR R VENTRIC RESCJ INFUND STEN W/WO COMMISSUROTOMY

Professional

Both

$3,142.00

Service Code	HCPCS 33476
Min. Negotiated Rate	$684.68
Max. Negotiated Rate	$2,397.99
Rate for Payer: Aetna Commercial	$2,042.75
Rate for Payer: Aetna Medicare	$1,571.00
Rate for Payer: BCBS Complete	$1,012.24
Rate for Payer: BCBS Trust/PPO	$684.68
Rate for Payer: BCN Commercial	$2,191.23
Rate for Payer: Cash Price	$2,513.60
Rate for Payer: Cash Price	$2,513.60
Rate for Payer: Meridian Medicaid	$1,012.24
Rate for Payer: Priority Health Choice Medicaid	$964.04
Rate for Payer: Priority Health Cigna Priority Health	$2,042.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,397.99
Rate for Payer: Priority Health Narrow Network	$2,397.99
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,967.94
Rate for Payer: UHC Exchange	$1,967.94
Rate for Payer: UHCCP Medicaid	$964.04

PR RX&FITG C-LENS SUPVJ CRNL LENS OU XCPT APHK

Professional

Both

$165.00

Service Code	HCPCS 92310
Min. Negotiated Rate	$36.00
Max. Negotiated Rate	$310.64
Rate for Payer: Aetna Commercial	$64.40
Rate for Payer: Aetna Medicare	$82.50
Rate for Payer: BCBS Complete	$37.80
Rate for Payer: BCBS Trust/PPO	$310.64
Rate for Payer: BCN Commercial	$145.62
Rate for Payer: Cash Price	$132.00
Rate for Payer: Cash Price	$132.00
Rate for Payer: Meridian Medicaid	$37.80
Rate for Payer: Priority Health Choice Medicaid	$36.00
Rate for Payer: Priority Health Cigna Priority Health	$107.25
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$70.18
Rate for Payer: Priority Health Narrow Network	$70.18
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$66.48
Rate for Payer: UHC Exchange	$66.48
Rate for Payer: UHCCP Medicaid	$36.00

PR RX&FITG C-LENS TECH CRNL LENS OU XCPT APHAKIA

Professional

Both

$137.00

Service Code	HCPCS 92314
Min. Negotiated Rate	$37.80
Max. Negotiated Rate	$686.79
Rate for Payer: Aetna Commercial	$37.80
Rate for Payer: Aetna Medicare	$68.50
Rate for Payer: BCBS Complete	$54.80
Rate for Payer: BCBS Trust/PPO	$686.79
Rate for Payer: BCN Commercial	$126.57
Rate for Payer: Cash Price	$109.60
Rate for Payer: Cash Price	$109.60
Rate for Payer: Priority Health Cigna Priority Health	$89.05
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$41.53
Rate for Payer: Priority Health Narrow Network	$41.53
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$39.06
Rate for Payer: UHC Exchange	$39.06

Know your out-of-pocket cost for care.

All Charges