Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

PR ANES HEART TRANSPLANT/HEART/LUNG TRANSPLANT

Professional

Both

$20.00

Service Code	HCPCS 00580
Min. Negotiated Rate	$8.00
Max. Negotiated Rate	$14.00
Rate for Payer: BCBS Complete	$8.00
Rate for Payer: Cash Price	$16.00
Rate for Payer: Priority Health Cigna Priority Health	$14.00

PR ANES HERNIA REPAIR LOWER ABDOMEN NOS & 1YR AGE

Professional

Both

$5.00

Service Code	HCPCS 00834
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$3.50
Rate for Payer: BCBS Complete	$2.00
Rate for Payer: Cash Price	$4.00
Rate for Payer: Priority Health Cigna Priority Health	$3.50

PR ANES HERNIA REPAIR UPPER ABDOMEN OMPHALOCELE

Professional

Both

$7.00

Service Code	HCPCS 00754
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$4.90
Rate for Payer: BCBS Complete	$2.80
Rate for Payer: Cash Price	$5.60
Rate for Payer: Priority Health Cigna Priority Health	$4.90

PR ANES HRNA REPAIR UPR ABD TABDL RPR DIPHRG HRNA

Professional

Both

$7.00

Service Code	HCPCS 00756
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$4.90
Rate for Payer: BCBS Complete	$2.80
Rate for Payer: Cash Price	$5.60
Rate for Payer: Priority Health Cigna Priority Health	$4.90

PR ANES HRNA RPR LWR ABD NOS INFTS <37WK BRTH/50WK

Professional

Both

$6.00

Service Code	HCPCS 00836
Min. Negotiated Rate	$2.40
Max. Negotiated Rate	$4.20
Rate for Payer: BCBS Complete	$2.40
Rate for Payer: Cash Price	$4.80
Rate for Payer: Priority Health Cigna Priority Health	$4.20

PR ANES HRNA RPR UPR ABD LMBR&VENTRAL HERNIA&DEHISC

Professional

Both

$6.00

Service Code	HCPCS 00752
Min. Negotiated Rate	$2.40
Max. Negotiated Rate	$4.20
Rate for Payer: BCBS Complete	$2.40
Rate for Payer: Cash Price	$4.80
Rate for Payer: Priority Health Cigna Priority Health	$4.20

PR ANES HRT PERICARDIAL SAC& GRT VESLS W/O PMP OXT

Professional

Both

$15.00

Service Code	HCPCS 00560
Min. Negotiated Rate	$6.00
Max. Negotiated Rate	$10.50
Rate for Payer: BCBS Complete	$6.00
Rate for Payer: Cash Price	$12.00
Rate for Payer: Priority Health Cigna Priority Health	$10.50

PR ANES HRT PERICARD SAC&GREAT VSLS W/PMP OXTJ <1YR

Professional

Both

$25.00

Service Code	HCPCS 00561
Min. Negotiated Rate	$10.00
Max. Negotiated Rate	$17.50
Rate for Payer: BCBS Complete	$10.00
Rate for Payer: Cash Price	$20.00
Rate for Payer: Priority Health Cigna Priority Health	$17.50

PR ANES HRT PERICRD SAC&GRT VSLS W/PMP OXTJ >1MO PO

Professional

Both

$20.00

Service Code	HCPCS 00562
Min. Negotiated Rate	$8.00
Max. Negotiated Rate	$14.00
Rate for Payer: BCBS Complete	$8.00
Rate for Payer: Cash Price	$16.00
Rate for Payer: Priority Health Cigna Priority Health	$14.00

PR ANES HRT PRCRD SAC & GREAT VSL W/PUMP OXTJ HYPTH

Professional

Both

$25.00

Service Code	HCPCS 00563
Min. Negotiated Rate	$10.00
Max. Negotiated Rate	$17.50
Rate for Payer: BCBS Complete	$10.00
Rate for Payer: Cash Price	$20.00
Rate for Payer: Priority Health Cigna Priority Health	$17.50

PR ANES HYSTEROSCOPY&/HYSTEROSALPINGOGRAPHY W/BX

Professional

Both

$4.00

Service Code	HCPCS 00952
Min. Negotiated Rate	$1.60
Max. Negotiated Rate	$2.80
Rate for Payer: BCBS Complete	$1.60
Rate for Payer: Cash Price	$3.20
Rate for Payer: Priority Health Cigna Priority Health	$2.80

PR ANES ICRA ICAR/AORTIC THER IVNTL RAD ARTL

Professional

Both

$8.00

Service Code	HCPCS 01926
Min. Negotiated Rate	$3.20
Max. Negotiated Rate	$5.60
Rate for Payer: BCBS Complete	$3.20
Rate for Payer: Cash Price	$6.40
Rate for Payer: Priority Health Cigna Priority Health	$5.60

PR ANES INSJ PENILE PROSTH PRNL INCL OPEN URTL

Professional

Both

$4.00

Service Code	HCPCS 00938
Min. Negotiated Rate	$1.60
Max. Negotiated Rate	$2.80
Rate for Payer: BCBS Complete	$1.60
Rate for Payer: Cash Price	$3.20
Rate for Payer: Priority Health Cigna Priority Health	$2.80

PR ANES INTEG EXTREMITIES ANT TRUNK & PERINEUM NOS

Professional

Both

$3.00

Service Code	HCPCS 00400
Min. Negotiated Rate	$1.20
Max. Negotiated Rate	$2.10
Rate for Payer: BCBS Complete	$1.20
Rate for Payer: Cash Price	$2.40
Rate for Payer: Priority Health Cigna Priority Health	$2.10

PR ANES INTEG MUSC & NRV HEAD NECK&POSTERIOR TRUNK

Professional

Both

$5.00

Service Code	HCPCS 00300
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$3.50
Rate for Payer: BCBS Complete	$2.00
Rate for Payer: Cash Price	$4.00
Rate for Payer: Priority Health Cigna Priority Health	$3.50

PR ANES INTEG SYS ELEC CONVERSION ARRHYTHMIAS

Professional

Both

$4.00

Service Code	HCPCS 00410
Min. Negotiated Rate	$1.60
Max. Negotiated Rate	$2.80
Rate for Payer: BCBS Complete	$1.60
Rate for Payer: Cash Price	$3.20
Rate for Payer: Priority Health Cigna Priority Health	$2.80

PR ANES INTRACRANIAL BURR HOLES W/VENTRICULOGRAPHY

Professional

Both

$9.00

Service Code	HCPCS 00214
Min. Negotiated Rate	$3.60
Max. Negotiated Rate	$6.30
Rate for Payer: BCBS Complete	$3.60
Rate for Payer: Cash Price	$7.20
Rate for Payer: Priority Health Cigna Priority Health	$6.30

PR ANES INTRACRANIAL CEREBROSPINAL FLUID SHUNTING

Professional

Both

$10.00

Service Code	HCPCS 00220
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$7.00
Rate for Payer: BCBS Complete	$4.00
Rate for Payer: Cash Price	$8.00
Rate for Payer: Priority Health Cigna Priority Health	$7.00

PR ANES INTRACRANIAL CRANIOTOMY/CRANIECTOMY HMTMA

Professional

Both

$10.00

Service Code	HCPCS 00211
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$7.00
Rate for Payer: BCBS Complete	$4.00
Rate for Payer: Cash Price	$8.00
Rate for Payer: Priority Health Cigna Priority Health	$7.00

PR ANES INTRACRANIAL ELECTROCOAGULATION ICRA NERVE

Professional

Both

$6.00

Service Code	HCPCS 00222
Min. Negotiated Rate	$2.40
Max. Negotiated Rate	$4.20
Rate for Payer: BCBS Complete	$2.40
Rate for Payer: Cash Price	$4.80
Rate for Payer: Priority Health Cigna Priority Health	$4.20

PR ANES INTRACRANIAL/ELEVATION DEPRSD SKULL FX XDRL

Professional

Both

$9.00

Service Code	HCPCS 00215
Min. Negotiated Rate	$3.60
Max. Negotiated Rate	$6.30
Rate for Payer: BCBS Complete	$3.60
Rate for Payer: Cash Price	$7.20
Rate for Payer: Priority Health Cigna Priority Health	$6.30

PR ANES INTRACRANIAL PROCEDURE IN SITTING POSITION

Professional

Both

$13.00

Service Code	HCPCS 00218
Min. Negotiated Rate	$5.20
Max. Negotiated Rate	$9.10
Rate for Payer: BCBS Complete	$5.20
Rate for Payer: Cash Price	$10.40
Rate for Payer: Priority Health Cigna Priority Health	$9.10

PR ANES INTRACRANIAL THER IVNTL RAD VENS/LYMPHTC

Professional

Both

$7.00

Service Code	HCPCS 01933
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$4.90
Rate for Payer: BCBS Complete	$2.80
Rate for Payer: Cash Price	$5.60
Rate for Payer: Priority Health Cigna Priority Health	$4.90

PR ANES INTRAORAL W/BIOPSY REPAIR CLEFT PALATE

Professional

Both

$6.00

Service Code	HCPCS 00172
Min. Negotiated Rate	$2.40
Max. Negotiated Rate	$4.20
Rate for Payer: BCBS Complete	$2.40
Rate for Payer: Cash Price	$4.80
Rate for Payer: Priority Health Cigna Priority Health	$4.20

PR ANES INTRAORAL W/BX EXC RETROPHARYNGEAL TUMOR

Professional

Both

$6.00

Service Code	HCPCS 00174
Min. Negotiated Rate	$2.40
Max. Negotiated Rate	$4.20
Rate for Payer: BCBS Complete	$2.40
Rate for Payer: Cash Price	$4.80
Rate for Payer: Priority Health Cigna Priority Health	$4.20

Know your out-of-pocket cost for care.

All Charges