Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

PR RX RIB FRACTURE W EXTERN FIXATN

Professional

Both

$1,317.00

Service Code	HCPCS 21810
Min. Negotiated Rate	$526.80
Max. Negotiated Rate	$856.05
Rate for Payer: Aetna Medicare	$658.50
Rate for Payer: BCBS Complete	$526.80
Rate for Payer: Cash Price	$1,053.60
Rate for Payer: Priority Health Cigna Priority Health	$856.05

PR SACRAL NERVE STIM TEST LEAD

Professional

Both

$163.00

Service Code	HCPCS A4290
Min. Negotiated Rate	$22.50
Max. Negotiated Rate	$902.34
Rate for Payer: Aetna Commercial	$57.67
Rate for Payer: Aetna Medicare	$81.50
Rate for Payer: BCBS Complete	$65.20
Rate for Payer: BCBS Trust/PPO	$902.34
Rate for Payer: BCN Commercial	$22.50
Rate for Payer: Cash Price	$130.40
Rate for Payer: Cash Price	$130.40
Rate for Payer: Priority Health Cigna Priority Health	$105.95
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$83.89
Rate for Payer: UHC Exchange	$83.89

PR SALPINGECTOMY COMPLETE/PARTIAL UNI/BI SPX

Professional

Both

$1,749.00

Service Code	HCPCS 58700
Min. Negotiated Rate	$138.94
Max. Negotiated Rate	$1,199.44
Rate for Payer: Aetna Commercial	$948.70
Rate for Payer: Aetna Medicare	$874.50
Rate for Payer: BCBS Complete	$541.45
Rate for Payer: BCBS Trust/PPO	$138.94
Rate for Payer: BCN Commercial	$1,174.29
Rate for Payer: Cash Price	$1,399.20
Rate for Payer: Cash Price	$1,399.20
Rate for Payer: Meridian Medicaid	$541.45
Rate for Payer: Priority Health Choice Medicaid	$515.67
Rate for Payer: Priority Health Cigna Priority Health	$1,136.85
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,199.44
Rate for Payer: Priority Health Narrow Network	$1,199.44
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$880.06
Rate for Payer: UHC Exchange	$880.06
Rate for Payer: UHCCP Medicaid	$515.67

PR SALPINGO-OOPHORECTOMY COMPL/PRTL UNI/BI SPX

Professional

Both

$2,041.00

Service Code	HCPCS 58720
Min. Negotiated Rate	$429.51
Max. Negotiated Rate	$1,326.65
Rate for Payer: Aetna Commercial	$897.45
Rate for Payer: Aetna Medicare	$1,020.50
Rate for Payer: BCBS Complete	$513.50
Rate for Payer: BCBS Trust/PPO	$429.51
Rate for Payer: BCN Commercial	$1,111.74
Rate for Payer: Cash Price	$1,632.80
Rate for Payer: Cash Price	$1,632.80
Rate for Payer: Meridian Medicaid	$513.50
Rate for Payer: Priority Health Choice Medicaid	$489.05
Rate for Payer: Priority Health Cigna Priority Health	$1,326.65
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,138.92
Rate for Payer: Priority Health Narrow Network	$1,138.92
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$821.53
Rate for Payer: UHC Exchange	$821.53
Rate for Payer: UHCCP Medicaid	$489.05

PR SALPINGOSTOMY

Professional

Both

$2,727.00

Service Code	HCPCS 58770
Min. Negotiated Rate	$209.21
Max. Negotiated Rate	$1,772.55
Rate for Payer: Aetna Commercial	$1,032.82
Rate for Payer: Aetna Medicare	$1,363.50
Rate for Payer: BCBS Complete	$579.47
Rate for Payer: BCBS Trust/PPO	$209.21
Rate for Payer: BCN Commercial	$1,266.17
Rate for Payer: Cash Price	$2,181.60
Rate for Payer: Cash Price	$2,181.60
Rate for Payer: Meridian Medicaid	$579.47
Rate for Payer: Priority Health Choice Medicaid	$551.88
Rate for Payer: Priority Health Cigna Priority Health	$1,772.55
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,288.73
Rate for Payer: Priority Health Narrow Network	$1,288.73
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$965.66
Rate for Payer: UHC Exchange	$965.66
Rate for Payer: UHCCP Medicaid	$551.88

PR SARSCOV2 VACC 10MCG/0.3ML TRIS-SUCROSE IM USE

Professional

Both

$219.00

Service Code	HCPCS 91319
Min. Negotiated Rate	$78.54
Max. Negotiated Rate	$142.35
Rate for Payer: Aetna Commercial	$87.78
Rate for Payer: Aetna Medicare	$109.50
Rate for Payer: BCBS Complete	$87.60
Rate for Payer: BCBS Trust/PPO	$78.54
Rate for Payer: Cash Price	$175.20
Rate for Payer: Cash Price	$175.20
Rate for Payer: Priority Health Cigna Priority Health	$142.35
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$105.34
Rate for Payer: UHC Exchange	$105.34

PR SARSCOV2 VACC 30MCG/0.3ML TRIS-SUCROSE IM USE

Professional

Both

$327.00

Service Code	HCPCS 91320
Min. Negotiated Rate	$125.00
Max. Negotiated Rate	$212.55
Rate for Payer: Aetna Commercial	$131.10
Rate for Payer: Aetna Medicare	$163.50
Rate for Payer: BCBS Complete	$130.80
Rate for Payer: BCBS Trust/PPO	$125.00
Rate for Payer: Cash Price	$261.60
Rate for Payer: Cash Price	$261.60
Rate for Payer: Priority Health Cigna Priority Health	$212.55
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$187.06
Rate for Payer: UHC Exchange	$187.06

PR SARSCOV2 VACC 3MCG/0.3ML TRIS-SUCROSE IM USE

Professional

Both

$164.00

Service Code	HCPCS 91318
Min. Negotiated Rate	$58.65
Max. Negotiated Rate	$106.60
Rate for Payer: Aetna Commercial	$65.36
Rate for Payer: Aetna Medicare	$82.00
Rate for Payer: BCBS Complete	$65.60
Rate for Payer: BCBS Trust/PPO	$58.65
Rate for Payer: Cash Price	$131.20
Rate for Payer: Cash Price	$131.20
Rate for Payer: Priority Health Cigna Priority Health	$106.60
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$78.66
Rate for Payer: UHC Exchange	$78.66

PR SBSQ HOSPITAL IP/OBS CARE HIGH MDM 50 MINUTES

Professional

Both

$184.00

Service Code	HCPCS 99233
Min. Negotiated Rate	$74.98
Max. Negotiated Rate	$1,858.56
Rate for Payer: Aetna Commercial	$101.64
Rate for Payer: Aetna Medicare	$92.00
Rate for Payer: BCBS Complete	$78.73
Rate for Payer: BCBS Trust/PPO	$1,858.56
Rate for Payer: BCN Commercial	$126.11
Rate for Payer: Cash Price	$147.20
Rate for Payer: Cash Price	$147.20
Rate for Payer: Meridian Medicaid	$78.73
Rate for Payer: Priority Health Choice Medicaid	$74.98
Rate for Payer: Priority Health Cigna Priority Health	$119.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$157.94
Rate for Payer: Priority Health Narrow Network	$157.94
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$110.04
Rate for Payer: UHC Exchange	$110.04
Rate for Payer: UHCCP Medicaid	$74.98

PR SBSQ HOSPITAL IP/OBS CARE MOD MDM 35 MINUTES

Professional

Both

$129.00

Service Code	HCPCS 99232
Min. Negotiated Rate	$50.27
Max. Negotiated Rate	$2,072.52
Rate for Payer: Aetna Commercial	$70.74
Rate for Payer: Aetna Medicare	$64.50
Rate for Payer: BCBS Complete	$52.78
Rate for Payer: BCBS Trust/PPO	$2,072.52
Rate for Payer: BCN Commercial	$83.83
Rate for Payer: Cash Price	$103.20
Rate for Payer: Cash Price	$103.20
Rate for Payer: Meridian Medicaid	$52.78
Rate for Payer: Priority Health Choice Medicaid	$50.27
Rate for Payer: Priority Health Cigna Priority Health	$83.85
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$105.00
Rate for Payer: Priority Health Narrow Network	$105.00
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$76.57
Rate for Payer: UHC Exchange	$76.57
Rate for Payer: UHCCP Medicaid	$50.27

PR SBSQ HOSPITAL IP/OBS CARE SF/LOW MDM 25 MINUTES

Professional

Both

$78.00

Service Code	HCPCS 99231
Min. Negotiated Rate	$31.10
Max. Negotiated Rate	$1,703.77
Rate for Payer: Aetna Commercial	$37.82
Rate for Payer: Aetna Medicare	$39.00
Rate for Payer: BCBS Complete	$32.66
Rate for Payer: BCBS Trust/PPO	$1,703.77
Rate for Payer: BCN Commercial	$52.66
Rate for Payer: Cash Price	$62.40
Rate for Payer: Cash Price	$62.40
Rate for Payer: Meridian Medicaid	$32.66
Rate for Payer: Priority Health Choice Medicaid	$31.10
Rate for Payer: Priority Health Cigna Priority Health	$50.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$65.96
Rate for Payer: Priority Health Narrow Network	$65.96
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$42.34
Rate for Payer: UHC Exchange	$42.34
Rate for Payer: UHCCP Medicaid	$31.10

PR SBSQ NURSING FACILITY CARE HIGH MDM 45 MINUTES

Professional

Both

$204.00

Service Code	HCPCS 99310
Min. Negotiated Rate	$97.77
Max. Negotiated Rate	$500.83
Rate for Payer: Aetna Commercial	$131.98
Rate for Payer: Aetna Medicare	$102.00
Rate for Payer: BCBS Complete	$102.66
Rate for Payer: BCBS Trust/PPO	$500.83
Rate for Payer: BCN Commercial	$221.37
Rate for Payer: Cash Price	$163.20
Rate for Payer: Cash Price	$163.20
Rate for Payer: Meridian Medicaid	$102.66
Rate for Payer: Priority Health Choice Medicaid	$97.77
Rate for Payer: Priority Health Cigna Priority Health	$132.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$205.52
Rate for Payer: Priority Health Narrow Network	$205.52
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$136.77
Rate for Payer: UHC Exchange	$136.77
Rate for Payer: UHCCP Medicaid	$97.77

PR SBSQ NURSING FACILITY CARE LOW MDM 20 MINUTES

Professional

Both

$103.00

Service Code	HCPCS 99308
Min. Negotiated Rate	$47.29
Max. Negotiated Rate	$2,410.10
Rate for Payer: Aetna Commercial	$67.42
Rate for Payer: Aetna Medicare	$51.50
Rate for Payer: BCBS Complete	$49.65
Rate for Payer: BCBS Trust/PPO	$2,410.10
Rate for Payer: BCN Commercial	$107.51
Rate for Payer: Cash Price	$82.40
Rate for Payer: Cash Price	$82.40
Rate for Payer: Meridian Medicaid	$49.65
Rate for Payer: Priority Health Choice Medicaid	$47.29
Rate for Payer: Priority Health Cigna Priority Health	$66.95
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$105.05
Rate for Payer: Priority Health Narrow Network	$105.05
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$69.93
Rate for Payer: UHC Exchange	$69.93
Rate for Payer: UHCCP Medicaid	$47.29

PR SBSQ NURSING FACILITY CARE MOD MDM 30 MINUTES

Professional

Both

$137.00

Service Code	HCPCS 99309
Min. Negotiated Rate	$68.50
Max. Negotiated Rate	$323.85
Rate for Payer: Aetna Commercial	$88.90
Rate for Payer: Aetna Medicare	$68.50
Rate for Payer: BCBS Complete	$72.02
Rate for Payer: BCBS Trust/PPO	$323.85
Rate for Payer: BCN Commercial	$153.93
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	$138.47
Rate for Payer: Priority Health Narrow Network	$138.47
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$92.04
Rate for Payer: UHC Exchange	$92.04
Rate for Payer: UHCCP Medicaid	$68.59

PR SBSQ NURSING FACILITY CARE SF MDM 10 MINUTES

Professional

Both

$67.00

Service Code	HCPCS 99307
Min. Negotiated Rate	$25.35
Max. Negotiated Rate	$2,395.31
Rate for Payer: Aetna Commercial	$42.96
Rate for Payer: Aetna Medicare	$33.50
Rate for Payer: BCBS Complete	$26.62
Rate for Payer: BCBS Trust/PPO	$2,395.31
Rate for Payer: BCN Commercial	$57.17
Rate for Payer: Cash Price	$53.60
Rate for Payer: Cash Price	$53.60
Rate for Payer: Meridian Medicaid	$26.62
Rate for Payer: Priority Health Choice Medicaid	$25.35
Rate for Payer: Priority Health Cigna Priority Health	$43.55
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$53.85
Rate for Payer: Priority Health Narrow Network	$53.85
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$45.41
Rate for Payer: UHC Exchange	$45.41
Rate for Payer: UHCCP Medicaid	$25.35

PR SBSQ OBSERVATION CARE/DAY 15 MINUTES

Professional

Both

$85.00

Service Code	HCPCS 99224
Min. Negotiated Rate	$34.00
Max. Negotiated Rate	$55.25
Rate for Payer: Aetna Medicare	$42.50
Rate for Payer: BCBS Complete	$34.00
Rate for Payer: Cash Price	$68.00
Rate for Payer: Priority Health Cigna Priority Health	$55.25

PR SBSQ OBSERVATION CARE/DAY 25 MINUTES

Professional

Both

$150.00

Service Code	HCPCS 99225
Min. Negotiated Rate	$60.00
Max. Negotiated Rate	$97.50
Rate for Payer: Aetna Medicare	$75.00
Rate for Payer: BCBS Complete	$60.00
Rate for Payer: Cash Price	$120.00
Rate for Payer: Priority Health Cigna Priority Health	$97.50

PR SBSQ OBSERVATION CARE/DAY 35 MINUTES

Professional

Both

$224.00

Service Code	HCPCS 99226
Min. Negotiated Rate	$89.60
Max. Negotiated Rate	$145.60
Rate for Payer: Aetna Medicare	$112.00
Rate for Payer: BCBS Complete	$89.60
Rate for Payer: Cash Price	$179.20
Rate for Payer: Priority Health Cigna Priority Health	$145.60

PR SBSQ PSYCHIATRIC COLLAB CARE MGMT 1ST 60 MINS

Professional

Both

$252.00

Service Code	HCPCS 99493
Min. Negotiated Rate	$65.18
Max. Negotiated Rate	$687.85
Rate for Payer: Aetna Commercial	$101.13
Rate for Payer: Aetna Medicare	$126.00
Rate for Payer: BCBS Complete	$68.44
Rate for Payer: BCBS Trust/PPO	$687.85
Rate for Payer: BCN Commercial	$154.35
Rate for Payer: Cash Price	$201.60
Rate for Payer: Cash Price	$201.60
Rate for Payer: Meridian Medicaid	$68.44
Rate for Payer: Priority Health Choice Medicaid	$65.18
Rate for Payer: Priority Health Cigna Priority Health	$163.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$154.29
Rate for Payer: Priority Health Narrow Network	$154.29
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$91.42
Rate for Payer: UHC Exchange	$91.42
Rate for Payer: UHCCP Medicaid	$65.18

PR SCLEROTHERAPY FLUID COLLECTION PRQ W/IMG GID

Professional

Both

$2,267.00

Service Code	HCPCS 49185
Min. Negotiated Rate	$75.40
Max. Negotiated Rate	$1,875.55
Rate for Payer: Aetna Commercial	$158.18
Rate for Payer: Aetna Medicare	$1,133.50
Rate for Payer: BCBS Complete	$79.17
Rate for Payer: BCBS Trust/PPO	$585.36
Rate for Payer: BCN Commercial	$1,875.55
Rate for Payer: Cash Price	$1,813.60
Rate for Payer: Cash Price	$1,813.60
Rate for Payer: Meridian Medicaid	$79.17
Rate for Payer: Priority Health Choice Medicaid	$75.40
Rate for Payer: Priority Health Cigna Priority Health	$1,473.55
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$208.21
Rate for Payer: Priority Health Narrow Network	$208.21
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$163.75
Rate for Payer: UHC Exchange	$163.75
Rate for Payer: UHCCP Medicaid	$75.40

PR SCREENING PAP SMEAR BY PHYS

Professional

Both

$64.00

Service Code	HCPCS P3001
Min. Negotiated Rate	$19.81
Max. Negotiated Rate	$2,624.07
Rate for Payer: Aetna Commercial	$19.81
Rate for Payer: Aetna Medicare	$32.00
Rate for Payer: BCBS Complete	$25.60
Rate for Payer: BCBS Trust/PPO	$2,624.07
Rate for Payer: BCN Commercial	$33.23
Rate for Payer: Cash Price	$51.20
Rate for Payer: Cash Price	$51.20
Rate for Payer: Priority Health Cigna Priority Health	$41.60
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$27.64
Rate for Payer: UHC Exchange	$27.64

PR SCREENING PROCTOSCOPY

Professional

Both

$154.00

Service Code	HCPCS S0601
Min. Negotiated Rate	$24.45
Max. Negotiated Rate	$100.10
Rate for Payer: Aetna Commercial	$24.45
Rate for Payer: Aetna Medicare	$77.00
Rate for Payer: BCBS Complete	$61.60
Rate for Payer: BCBS Trust/PPO	$45.43
Rate for Payer: BCN Commercial	$67.02
Rate for Payer: Cash Price	$123.20
Rate for Payer: Cash Price	$123.20
Rate for Payer: Priority Health Cigna Priority Health	$100.10

PR SCREENING TEST PURE TONE AIR ONLY

Professional

Both

$29.00

Service Code	HCPCS 92551
Min. Negotiated Rate	$10.85
Max. Negotiated Rate	$1,709.05
Rate for Payer: Aetna Commercial	$12.13
Rate for Payer: Aetna Medicare	$14.50
Rate for Payer: BCBS Complete	$11.60
Rate for Payer: BCBS Trust/PPO	$1,709.05
Rate for Payer: BCN Commercial	$17.59
Rate for Payer: Cash Price	$23.20
Rate for Payer: Cash Price	$23.20
Rate for Payer: Priority Health Cigna Priority Health	$18.85
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$17.19
Rate for Payer: Priority Health Narrow Network	$17.19
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$10.85
Rate for Payer: UHC Exchange	$10.85

PR SCREENING TEST VISUAL ACUITY QUANTITATIVE BILAT

Professional

Both

$23.00

Service Code	HCPCS 99173
Min. Negotiated Rate	$2.78
Max. Negotiated Rate	$1,121.05
Rate for Payer: Aetna Commercial	$3.23
Rate for Payer: Aetna Medicare	$11.50
Rate for Payer: BCBS Complete	$9.20
Rate for Payer: BCBS Trust/PPO	$1,121.05
Rate for Payer: BCN Commercial	$4.39
Rate for Payer: Cash Price	$18.40
Rate for Payer: Cash Price	$18.40
Rate for Payer: Priority Health Cigna Priority Health	$14.95
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$4.52
Rate for Payer: Priority Health Narrow Network	$4.52
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$2.78
Rate for Payer: UHC Exchange	$2.78

PR SCR MAMMO BI INCL CAD

Professional

Both

$207.00

Service Code	HCPCS G0202
Min. Negotiated Rate	$82.80
Max. Negotiated Rate	$134.55
Rate for Payer: Aetna Medicare	$103.50
Rate for Payer: BCBS Complete	$82.80
Rate for Payer: Cash Price	$165.60
Rate for Payer: Priority Health Cigna Priority Health	$134.55

Know your out-of-pocket cost for care.

All Charges