Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

PR ANES NOSE & ACCESSORY SINUSES RADICAL SURGERY

Professional

Both

$7.00

Service Code	HCPCS 00162
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 NRV MUSC TDN FSCA&BRS UPR ARM/ELBOW NOS

Professional

Both

$3.00

Service Code	HCPCS 01710
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 NRV MUSC TNDN FSCIA BURSA SHOULDER & AXILLA

Professional

Both

$5.00

Service Code	HCPCS 01610
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 NRV/MUS/TND/FASC LOWER LEG/ANKLE/FOOT NOS

Professional

Both

$3.00

Service Code	HCPCS 01470
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 OPEN OSTEOTOMY/OSTEOPLASTY TIBIA&/FIBULA

Professional

Both

$4.00

Service Code	HCPCS 01484
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 OPEN PROC BONES LOWER LEG/ANKLE/FOOT NOS

Professional

Both

$3.00

Service Code	HCPCS 01480
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 OPEN PROC UPPER ENDS TIBIA FIBULA&/PATELLA

Professional

Both

$4.00

Service Code	HCPCS 01392
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 OPEN/SURG ARTHROSCOPIC ELBOW PROC NOS

Professional

Both

$4.00

Service Code	HCPCS 01740
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 OPEN/SURG ARTHROSCOPIC PROC KNEE JOINT NOS

Professional

Both

$4.00

Service Code	HCPCS 01400
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 OPEN/SURG ARTHRS REPRS NON/MALUNION HUMERUS

Professional

Both

$5.00

Service Code	HCPCS 01744
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 OPEN SYMPHYSIS PUBIS/SACROILIAC JOINT

Professional

Both

$8.00

Service Code	HCPCS 01170
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 OPN RPR DISRPJ PELVIS/COLUMN FX ACETABULUM

Professional

Both

$12.00

Service Code	HCPCS 01173
Min. Negotiated Rate	$4.80
Max. Negotiated Rate	$8.40
Rate for Payer: BCBS Complete	$4.80
Rate for Payer: Cash Price	$9.60
Rate for Payer: Priority Health Cigna Priority Health	$8.40

PR ANES ORCHIOPEXY UNI/BI INCL OPEN URETHRAL PX

Professional

Both

$4.00

Service Code	HCPCS 00930
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 PERMANENT TRANSVENOUS PACEMAKER INSERTION

Professional

Both

$4.00

Service Code	HCPCS 00530
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 PERQ IMG NJX DRG/ASPIR PX SPI/SP CRV/THRC

Professional

Both

$338.00

Service Code	HCPCS 01937
Min. Negotiated Rate	$135.20
Max. Negotiated Rate	$236.60
Rate for Payer: BCBS Complete	$135.20
Rate for Payer: Cash Price	$270.40
Rate for Payer: Priority Health Cigna Priority Health	$236.60

PR ANES RAD AMP PENIS W/BI INGUINAL LYMPH NODE RMVL

Professional

Both

$6.00

Service Code	HCPCS 00934
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 RAD AMP PENIS W/BI INGUNL&ILIAC LYMPH RMOVL

Professional

Both

$8.00

Service Code	HCPCS 00936
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 RADICAL/MODIFIED RADICAL BREAST W/NODES

Professional

Both

$13.00

Service Code	HCPCS 00406
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 RADICAL RESECJ INCL BELOW KNEE AMPUTATION

Professional

Both

$4.00

Service Code	HCPCS 01482
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 RADICAL TUMOR PELVIS XCP HINDQUARTER AMP

Professional

Both

$10.00

Service Code	HCPCS 01150
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 RADIUS ULNA WRIST/HAND BONES CLOSED PX

Professional

Both

$3.00

Service Code	HCPCS 01820
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 RAD ORCHIECTOMY ABDOMINAL INCL OPN URTL

Professional

Both

$6.00

Service Code	HCPCS 00928
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 RAD ORCHIECTOMY INGUN INCL OPEN URTL PX

Professional

Both

$4.00

Service Code	HCPCS 00926
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 RPR RUPTURED ACHILLES TENDON W/WO GRAFT

Professional

Both

$5.00

Service Code	HCPCS 01472
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 SEMINAL VESICLES INCL OPEN URETHRAL PX

Professional

Both

$6.00

Service Code	HCPCS 00922
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