Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

PR ANESTHESIA EYELID RECONSTRUCTIVE PROCEDURE

Professional

Both

$5.00

Service Code	HCPCS 00103
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 ANESTHESIA EYE NOT OTHERWISE SPECIFIED

Professional

Both

$5.00

Service Code	HCPCS 00140
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 ANESTHESIA EYE OPHTHALMOSCOPY

Professional

Both

$4.00

Service Code	HCPCS 00148
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 ANESTHESIA EYE VITREORETINAL SURGERY

Professional

Both

$6.00

Service Code	HCPCS 00145
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 ANESTHESIA FACIAL BONES OR SKULL NOS

Professional

Both

$5.00

Service Code	HCPCS 00190
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 ANESTHESIA FOR STERNAL DEBRIDEMENT

Professional

Both

$10.00

Service Code	HCPCS 00550
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 ANESTHESIA GASTROCNEMIUS RECESSION

Professional

Both

$5.00

Service Code	HCPCS 01474
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 ANESTHESIA HERNIA REPAIR LOWER ABDOMEN NOS

Professional

Both

$4.00

Service Code	HCPCS 00830
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 ANESTHESIA HERNIA REPAIR UPPER ABDOMEN NOS

Professional

Both

$4.00

Service Code	HCPCS 00750
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 ANESTHESIA INCOMPLETE/MISSED ABORTION

Professional

Both

$4.00

Service Code	HCPCS 01965
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 ANESTHESIA INDUCED ABORTION

Professional

Both

$4.00

Service Code	HCPCS 01966
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 ANESTHESIA INTERPELVI ABDOMINAL AMPUTATION

Professional

Both

$15.00

Service Code	HCPCS 01140
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 ANESTHESIA INTRACRANIAL PROCEDURE NOS

Professional

Both

$11.00

Service Code	HCPCS 00210
Min. Negotiated Rate	$4.40
Max. Negotiated Rate	$7.70
Rate for Payer: BCBS Complete	$4.40
Rate for Payer: Cash Price	$8.80
Rate for Payer: Priority Health Cigna Priority Health	$7.70

PR ANESTHESIA INTRACRANIAL PROCEDURE SUBDURAL TAPS

Professional

Both

$5.00

Service Code	HCPCS 00212
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 ANESTHESIA INTRACRANIAL VASCULAR PROCEDURE

Professional

Both

$15.00

Service Code	HCPCS 00216
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 ANESTHESIA INTRAHEPATIC/PORTAL THER IVNTL RAD

Professional

Both

$7.00

Service Code	HCPCS 01931
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 ANESTHESIA INTRAORAL W/BIOPSY RADICAL SURGERY

Professional

Both

$7.00

Service Code	HCPCS 00176
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 ANESTHESIA INTRAORAL WITH BIOPSY NOS

Professional

Both

$5.00

Service Code	HCPCS 00170
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 ANESTHESIA INTRAPERITONEAL LOWER ABD W/LAPS NOS

Professional

Both

$6.00

Service Code	HCPCS 00840
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 ANESTHESIA INTRATHORACIC/JUGULAR THER IVNTL RAD

Professional

Both

$6.00

Service Code	HCPCS 01932
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 ANESTHESIA LARYNX & TRACHEA CHILDREN <1 YEAR

Professional

Both

$7.00

Service Code	HCPCS 00326
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 ANESTHESIA LOWER ANTERIOR ABDOMINAL WALL NOS

Professional

Both

$4.00

Service Code	HCPCS 00800
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 ANESTHESIA LOWER INTST ENDOSCOPIC PX NOS

Professional

Both

$1.00

Service Code	HCPCS 00811
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.70
Rate for Payer: BCBS Complete	$0.40
Rate for Payer: Cash Price	$0.80
Rate for Payer: Priority Health Cigna Priority Health	$0.70

PR ANESTHESIA LOWER INTST ENDOSCOPIC PX SCR COLSC

Professional

Both

$1.00

Service Code	HCPCS 00812
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.70
Rate for Payer: BCBS Complete	$0.40
Rate for Payer: Cash Price	$0.80
Rate for Payer: Priority Health Cigna Priority Health	$0.70

PR ANESTHESIA LOWER POSTERIOR ABDOMINAL WALL

Professional

Both

$5.00

Service Code	HCPCS 00820
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

Know your out-of-pocket cost for care.

All Charges