Bronson Lakeview Hospital

All Charges

Charge

Type

Setting

Price

PR ANESTHESIA CLAVICLE & SCAPULA BIOPSY CLAVICLE

Professional

Both

$3.00

Service Code	HCPCS 00454
Min. Negotiated Rate	$1.20
Max. Negotiated Rate	$1.95
Rate for Payer: Aetna Medicare	$1.50
Rate for Payer: BCBS Complete	$1.20
Rate for Payer: Cash Price	$2.40
Rate for Payer: Priority Health Cigna Priority Health	$1.95

PR ANESTHESIA CLEFT LIP INVOLVING PLASTIC REPAIR

Professional

Both

$6.00

Service Code	HCPCS 00102
Min. Negotiated Rate	$2.40
Max. Negotiated Rate	$3.90
Rate for Payer: Aetna Medicare	$3.00
Rate for Payer: BCBS Complete	$2.40
Rate for Payer: Cash Price	$4.80
Rate for Payer: Priority Health Cigna Priority Health	$3.90

PR ANESTHESIA CLOSED CHEST NEEDLE BIOPSY PLEURA

Professional

Both

$4.00

Service Code	HCPCS 00522
Min. Negotiated Rate	$1.60
Max. Negotiated Rate	$2.60
Rate for Payer: Aetna Medicare	$2.00
Rate for Payer: BCBS Complete	$1.60
Rate for Payer: Cash Price	$3.20
Rate for Payer: Priority Health Cigna Priority Health	$2.60

PR ANESTHESIA CLOSED CHEST PNEUMOCENTESIS

Professional

Both

$4.00

Service Code	HCPCS 00524
Min. Negotiated Rate	$1.60
Max. Negotiated Rate	$2.60
Rate for Payer: Aetna Medicare	$2.00
Rate for Payer: BCBS Complete	$1.60
Rate for Payer: Cash Price	$3.20
Rate for Payer: Priority Health Cigna Priority Health	$2.60

PR ANESTHESIA CLOSED CHEST W/BRONCHOSCOPY NOS

Professional

Both

$6.00

Service Code	HCPCS 00520
Min. Negotiated Rate	$2.40
Max. Negotiated Rate	$3.90
Rate for Payer: Aetna Medicare	$3.00
Rate for Payer: BCBS Complete	$2.40
Rate for Payer: Cash Price	$4.80
Rate for Payer: Priority Health Cigna Priority Health	$3.90

PR ANESTHESIA CLOSED HIP JOINT PROCEDURE

Professional

Both

$4.00

Service Code	HCPCS 01200
Min. Negotiated Rate	$1.60
Max. Negotiated Rate	$2.60
Rate for Payer: Aetna Medicare	$2.00
Rate for Payer: BCBS Complete	$1.60
Rate for Payer: Cash Price	$3.20
Rate for Payer: Priority Health Cigna Priority Health	$2.60

PR ANESTHESIA CLOSED PROCEDURES HUMERUS & ELBOW

Professional

Both

$3.00

Service Code	HCPCS 01730
Min. Negotiated Rate	$1.20
Max. Negotiated Rate	$1.95
Rate for Payer: Aetna Medicare	$1.50
Rate for Payer: BCBS Complete	$1.20
Rate for Payer: Cash Price	$2.40
Rate for Payer: Priority Health Cigna Priority Health	$1.95

PR ANESTHESIA CLOSED PROCEDURES KNEE JOINT

Professional

Both

$3.00

Service Code	HCPCS 01380
Min. Negotiated Rate	$1.20
Max. Negotiated Rate	$1.95
Rate for Payer: Aetna Medicare	$1.50
Rate for Payer: BCBS Complete	$1.20
Rate for Payer: Cash Price	$2.40
Rate for Payer: Priority Health Cigna Priority Health	$1.95

PR ANESTHESIA CLOSED PROCEDURES LOWER 1/3 FEMUR

Professional

Both

$4.00

Service Code	HCPCS 01340
Min. Negotiated Rate	$1.60
Max. Negotiated Rate	$2.60
Rate for Payer: Aetna Medicare	$2.00
Rate for Payer: BCBS Complete	$1.60
Rate for Payer: Cash Price	$3.20
Rate for Payer: Priority Health Cigna Priority Health	$2.60

PR ANESTHESIA CLOSED PROCEDURES UPPER 2/3 FEMUR

Professional

Both

$4.00

Service Code	HCPCS 01220
Min. Negotiated Rate	$1.60
Max. Negotiated Rate	$2.60
Rate for Payer: Aetna Medicare	$2.00
Rate for Payer: BCBS Complete	$1.60
Rate for Payer: Cash Price	$3.20
Rate for Payer: Priority Health Cigna Priority Health	$2.60

PR ANESTHESIA CLOSED PROC LOWER LEG ANKLE & FOOT

Professional

Both

$3.00

Service Code	HCPCS 01462
Min. Negotiated Rate	$1.20
Max. Negotiated Rate	$1.95
Rate for Payer: Aetna Medicare	$1.50
Rate for Payer: BCBS Complete	$1.20
Rate for Payer: Cash Price	$2.40
Rate for Payer: Priority Health Cigna Priority Health	$1.95

PR ANESTHESIA COMBINED UPPER&LOWER GI ENDOSCOPIC PX

Professional

Both

$1.00

Service Code	HCPCS 00813
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.65
Rate for Payer: Aetna Medicare	$0.50
Rate for Payer: BCBS Complete	$0.40
Rate for Payer: Cash Price	$0.80
Rate for Payer: Priority Health Cigna Priority Health	$0.65

PR ANESTHESIA CULDOSCOPY INCLUDING BIOPSY

Professional

Both

$5.00

Service Code	HCPCS 00950
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$3.25
Rate for Payer: Aetna Medicare	$2.50
Rate for Payer: BCBS Complete	$2.00
Rate for Payer: Cash Price	$4.00
Rate for Payer: Priority Health Cigna Priority Health	$3.25

PR ANESTHESIA DIAGNOSTIC ARTERIOGRAPHY/VENOGRAPH

Professional

Both

$5.00

Service Code	HCPCS 01916
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$3.25
Rate for Payer: Aetna Medicare	$2.50
Rate for Payer: BCBS Complete	$2.00
Rate for Payer: Cash Price	$4.00
Rate for Payer: Priority Health Cigna Priority Health	$3.25

PR ANESTHESIA DIAGNOSTIC ARTHROSCOPIC PROC WRIST

Professional

Both

$3.00

Service Code	HCPCS 01829
Min. Negotiated Rate	$1.20
Max. Negotiated Rate	$1.95
Rate for Payer: Aetna Medicare	$1.50
Rate for Payer: BCBS Complete	$1.20
Rate for Payer: Cash Price	$2.40
Rate for Payer: Priority Health Cigna Priority Health	$1.95

PR ANESTHESIA ELBOW JOINT DIAGNOSTIC ARTHROSCOPIC

Professional

Both

$3.00

Service Code	HCPCS 01732
Min. Negotiated Rate	$1.20
Max. Negotiated Rate	$1.95
Rate for Payer: Aetna Medicare	$1.50
Rate for Payer: BCBS Complete	$1.20
Rate for Payer: Cash Price	$2.40
Rate for Payer: Priority Health Cigna Priority Health	$1.95

PR ANESTHESIA ELECTROCONVULSIVE THERAPY

Professional

Both

$4.00

Service Code	HCPCS 00104
Min. Negotiated Rate	$1.60
Max. Negotiated Rate	$2.60
Rate for Payer: Aetna Medicare	$2.00
Rate for Payer: BCBS Complete	$1.60
Rate for Payer: Cash Price	$3.20
Rate for Payer: Priority Health Cigna Priority Health	$2.60

PR ANESTHESIA ESOPHAGUS

Professional

Both

$15.00

Service Code	HCPCS 00500
Min. Negotiated Rate	$6.00
Max. Negotiated Rate	$9.75
Rate for Payer: Aetna Medicare	$7.50
Rate for Payer: BCBS Complete	$6.00
Rate for Payer: Cash Price	$12.00
Rate for Payer: Priority Health Cigna Priority Health	$9.75

PR ANESTHESIA EXTENSIVE SPINE & SPINAL CORD

Professional

Both

$13.00

Service Code	HCPCS 00670
Min. Negotiated Rate	$5.20
Max. Negotiated Rate	$8.45
Rate for Payer: Aetna Medicare	$6.50
Rate for Payer: BCBS Complete	$5.20
Rate for Payer: Cash Price	$10.40
Rate for Payer: Priority Health Cigna Priority Health	$8.45

PR ANESTHESIA EXTERNAL CEPHALIC VERSION

Professional

Both

$5.00

Service Code	HCPCS 01958
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$3.25
Rate for Payer: Aetna Medicare	$2.50
Rate for Payer: BCBS Complete	$2.00
Rate for Payer: Cash Price	$4.00
Rate for Payer: Priority Health Cigna Priority Health	$3.25

PR ANESTHESIA EXTERNAL MIDDLE & INNER EAR W/BX NOS

Professional

Both

$5.00

Service Code	HCPCS 00120
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$3.25
Rate for Payer: Aetna Medicare	$2.50
Rate for Payer: BCBS Complete	$2.00
Rate for Payer: Cash Price	$4.00
Rate for Payer: Priority Health Cigna Priority Health	$3.25

PR ANESTHESIA EXTREME AGE PATIENT<1 YR&>70

Professional

Both

$98.00

Service Code	HCPCS 99100
Min. Negotiated Rate	$39.20
Max. Negotiated Rate	$617.05
Rate for Payer: Aetna Commercial	$52.00
Rate for Payer: Aetna Medicare	$49.00
Rate for Payer: BCBS Complete	$39.20
Rate for Payer: BCBS Trust/PPO	$617.05
Rate for Payer: Cash Price	$78.40
Rate for Payer: Cash Price	$78.40
Rate for Payer: Priority Health Cigna Priority Health	$63.70
Rate for Payer: Priority Health HMO/PPO	$50.00
Rate for Payer: Priority Health Narrow/Tiered Network	$50.00

PR ANESTHESIA EYE CORNEAL TRANSPLANT

Professional

Both

$6.00

Service Code	HCPCS 00144
Min. Negotiated Rate	$2.40
Max. Negotiated Rate	$3.90
Rate for Payer: Aetna Medicare	$3.00
Rate for Payer: BCBS Complete	$2.40
Rate for Payer: Cash Price	$4.80
Rate for Payer: Priority Health Cigna Priority Health	$3.90

PR ANESTHESIA EYE IRIDECTOMY

Professional

Both

$4.00

Service Code	HCPCS 00147
Min. Negotiated Rate	$1.60
Max. Negotiated Rate	$2.60
Rate for Payer: Aetna Medicare	$2.00
Rate for Payer: BCBS Complete	$1.60
Rate for Payer: Cash Price	$3.20
Rate for Payer: Priority Health Cigna Priority Health	$2.60

PR ANESTHESIA EYE LENS SURGERY

Professional

Both

$4.00

Service Code	HCPCS 00142
Min. Negotiated Rate	$1.60
Max. Negotiated Rate	$2.60
Rate for Payer: Aetna Medicare	$2.00
Rate for Payer: BCBS Complete	$1.60
Rate for Payer: Cash Price	$3.20
Rate for Payer: Priority Health Cigna Priority Health	$2.60

Know your out-of-pocket cost for care.

All Charges