Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

PR ANESTH OPEN/SURG ARTHRS KNEE DISARTICULATION

Professional

Both

$5.00

Service Code	HCPCS 01404
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 ANESTH OPEN/SURG ARTHRS TOTAL ELBOW REPLACEMENT

Professional

Both

$7.00

Service Code	HCPCS 01760
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 ANESTH OPEN/SURG ARTHRS TOTAL KNEE ARTHROPLASTY

Professional

Both

$7.00

Service Code	HCPCS 01402
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 THORACIC SPINE & CORD ANT APPR W/1 LNG VENT

Professional

Both

$15.00

Service Code	HCPCS 00626
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 THORACOTOMY & THORACOSCOPY DECORTICATION

Professional

Both

$15.00

Service Code	HCPCS 00542
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 THORACOTOMY & THORACOSCOPY NOS

Professional

Both

$12.00

Service Code	HCPCS 00540
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 THORACOTOMY & THORACOSCOPY PULMONARY RESC

Professional

Both

$15.00

Service Code	HCPCS 00546
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 THORACOTOMY & THORACOSCOPY W/1 LUNG VNTJ

Professional

Both

$15.00

Service Code	HCPCS 00541
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 THORACOTOMY &THORACSCOPY TRACHEA & BRONCHI

Professional

Both

$17.00

Service Code	HCPCS 00548
Min. Negotiated Rate	$6.80
Max. Negotiated Rate	$11.90
Rate for Payer: BCBS Complete	$6.80
Rate for Payer: Cash Price	$13.60
Rate for Payer: Priority Health Cigna Priority Health	$11.90

PR ANESTH,PELV NERV REMOVAL EXTRAPELV

Professional

Both

$3.00

Service Code	HCPCS 01180
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 ANESTH,PELV NERV REMOVAL INTRAPELV

Professional

Both

$4.00

Service Code	HCPCS 01190
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 ANESTH,PERC IMAGE GUIDE SPINAL PROC, DIAG

Professional

Both

$5.00

Service Code	HCPCS 01935
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 ANESTH,PERC IMAGE GUIDE SPINAL PROC, THER

Professional

Both

$5.00

Service Code	HCPCS 01936
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 ANESTH,RAD SURG CLAVICLE/SCAPULA

Professional

Both

$6.00

Service Code	HCPCS 00452
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 THRC SPINE & CORD ANT APPR W/O 1 LUNG VENTJ

Professional

Both

$13.00

Service Code	HCPCS 00625
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 ANESTH,SHOULDER SPICA

Professional

Both

$4.00

Service Code	HCPCS 01682
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 ANESTH,THORACOLUMBAR SYMPATHECTOMY

Professional

Both

$13.00

Service Code	HCPCS 00622
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 ANESTH,UGI ENDOSCOPY

Professional

Both

$5.00

Service Code	HCPCS 00740
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 TRANSURETHRAL RESECTION OF BLADDER TUMOR

Professional

Both

$5.00

Service Code	HCPCS 00912
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 TRANSURETHRAL W/URETHROCYSTOSCOPY NOS

Professional

Both

$3.00

Service Code	HCPCS 00910
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 TRANSVENOUS INSJ/REPLACEMENT PACING CVDFB

Professional

Both

$7.00

Service Code	HCPCS 00534
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 TRURL FRAGMNTJ MANJ&/RMVL URETERAL CALCULUS

Professional

Both

$5.00

Service Code	HCPCS 00918
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 TRURL POST-TRURL RESECTION BLEEDING

Professional

Both

$5.00

Service Code	HCPCS 00916
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 UNDSCND TESTIS UNI/BI INCL OPEN URTL PX

Professional

Both

$4.00

Service Code	HCPCS 00924
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 UPPER 2/3 FEMUR RADICAL RESCECTION

Professional

Both

$8.00

Service Code	HCPCS 01234
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

Know your out-of-pocket cost for care.

All Charges