Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

PR ANES OPEN/SURG ARTHROSCOPIC PX KNEE JOINT NOS

Professional

Both

$4.00

Service Code	HCPCS 01400
Min. Negotiated Rate	$1.60
Max. Negotiated Rate	$3.00
Rate for Payer: BCBS Complete	$1.60
Rate for Payer: Cash Price	$3.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$3.00

PR ANES OPEN/SURG ARTHRS DISARTICULATION AT KNEE

Professional

Both

$5.00

Service Code	HCPCS 01404
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$3.75
Rate for Payer: BCBS Complete	$2.00
Rate for Payer: Cash Price	$4.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$3.75

PR ANES OPEN/SURG ARTHRS PX ELBW TOTAL ELBOW RPLCMT

Professional

Both

$7.00

Service Code	HCPCS 01760
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$5.25
Rate for Payer: BCBS Complete	$2.80
Rate for Payer: Cash Price	$5.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$5.25

PR ANES OPEN/SURG ARTHRS TOTAL KNEE ARTHROPLASTY

Professional

Both

$7.00

Service Code	HCPCS 01402
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$5.25
Rate for Payer: BCBS Complete	$2.80
Rate for Payer: Cash Price	$5.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$5.25

PR ANES OPN/ARTHR HUMRL H/N STRNCLV ACRMCLV&SHO NOS

Professional

Both

$5.00

Service Code	HCPCS 01630
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$3.75
Rate for Payer: BCBS Complete	$2.00
Rate for Payer: Cash Price	$4.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$3.75

PR ANES OPN/ARTHROSCOPIC TOTAL SHOULDER REPLACEMENT

Professional

Both

$10.00

Service Code	HCPCS 01638
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$7.50
Rate for Payer: BCBS Complete	$4.00
Rate for Payer: Cash Price	$8.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$7.50

PR ANES OPN RPR FX DISRPJ PLVS/COLUMN FX ACETABULUM

Professional

Both

$12.00

Service Code	HCPCS 01173
Min. Negotiated Rate	$4.80
Max. Negotiated Rate	$9.00
Rate for Payer: BCBS Complete	$4.80
Rate for Payer: Cash Price	$9.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$9.00

PR ANES OPN/SURG ARTHRS PX ELBW EXC CST/TUM HUMERUS

Professional

Both

$5.00

Service Code	HCPCS 01758
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$3.75
Rate for Payer: BCBS Complete	$2.00
Rate for Payer: Cash Price	$4.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$3.75

PR ANES OPN/SURG ARTHRS PX ELBW RPR NON/MALUN HUM

Professional

Both

$5.00

Service Code	HCPCS 01744
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$3.75
Rate for Payer: BCBS Complete	$2.00
Rate for Payer: Cash Price	$4.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$3.75

PR ANES PERMANENT TRANSVENOUS PACEMAKER INSERTION

Professional

Both

$4.00

Service Code	HCPCS 00530
Min. Negotiated Rate	$1.60
Max. Negotiated Rate	$3.00
Rate for Payer: BCBS Complete	$1.60
Rate for Payer: Cash Price	$3.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$3.00

PR ANES PERQ IMG NJX DRG/ASPIR PX SPI/SP CRV/THRC

Professional

Both

$355.00

Service Code	HCPCS 01937
Min. Negotiated Rate	$142.00
Max. Negotiated Rate	$266.25
Rate for Payer: BCBS Complete	$142.00
Rate for Payer: Cash Price	$284.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$266.25

PR ANES PX ARTERIES FOREARM WRIST&HAND EMBOLECTOMY

Professional

Both

$6.00

Service Code	HCPCS 01842
Min. Negotiated Rate	$2.40
Max. Negotiated Rate	$4.50
Rate for Payer: BCBS Complete	$2.40
Rate for Payer: Cash Price	$4.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$4.50

PR ANES PX ARTERIES OF KNEE & POPLITEAL AREA NOS

Professional

Both

$8.00

Service Code	HCPCS 01440
Min. Negotiated Rate	$3.20
Max. Negotiated Rate	$6.00
Rate for Payer: BCBS Complete	$3.20
Rate for Payer: Cash Price	$6.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$6.00

PR ANES PX ARTERIES SHOULDER&AXILLA BYPASS GRAFT

Professional

Both

$8.00

Service Code	HCPCS 01654
Min. Negotiated Rate	$3.20
Max. Negotiated Rate	$6.00
Rate for Payer: BCBS Complete	$3.20
Rate for Payer: Cash Price	$6.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$6.00

PR ANES PX ART KNEE&POP EXC&GRF/RPR OCCLS/ANEURYSM

Professional

Both

$8.00

Service Code	HCPCS 01444
Min. Negotiated Rate	$3.20
Max. Negotiated Rate	$6.00
Rate for Payer: BCBS Complete	$3.20
Rate for Payer: Cash Price	$6.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$6.00

PR ANES PX ART KNEE&POPLITEAL TEAEC W/WO PATCH GRF

Professional

Both

$8.00

Service Code	HCPCS 01442
Min. Negotiated Rate	$3.20
Max. Negotiated Rate	$6.00
Rate for Payer: BCBS Complete	$3.20
Rate for Payer: Cash Price	$6.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$6.00

PR ANES PX ART LWR LEG W/BYP GRAFT EMBLC DIR/W/CATH

Professional

Both

$6.00

Service Code	HCPCS 01502
Min. Negotiated Rate	$2.40
Max. Negotiated Rate	$4.50
Rate for Payer: BCBS Complete	$2.40
Rate for Payer: Cash Price	$4.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$4.50

PR ANES PX ART SHO&AX AXILLARY-BRACHIAL ANEURYSM

Professional

Both

$10.00

Service Code	HCPCS 01652
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$7.50
Rate for Payer: BCBS Complete	$4.00
Rate for Payer: Cash Price	$8.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$7.50

PR ANES PX ART SHO&AX AXILLARY-FEMORAL BYPASS GRAFT

Professional

Both

$10.00

Service Code	HCPCS 01656
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$7.50
Rate for Payer: BCBS Complete	$4.00
Rate for Payer: Cash Price	$8.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$7.50

PR ANES PX ART UPPER LEG W/BYPASS GRAFT FEM ART LIG

Professional

Both

$4.00

Service Code	HCPCS 01272
Min. Negotiated Rate	$1.60
Max. Negotiated Rate	$3.00
Rate for Payer: BCBS Complete	$1.60
Rate for Payer: Cash Price	$3.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$3.00

PR ANES PX ART UPR LEG BYPASS GRAFT FEM ART EMBLC

Professional

Both

$6.00

Service Code	HCPCS 01274
Min. Negotiated Rate	$2.40
Max. Negotiated Rate	$4.50
Rate for Payer: BCBS Complete	$2.40
Rate for Payer: Cash Price	$4.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$4.50

PR ANES PX CERVICAL SPINE & CORD W/PATIENT SITTING

Professional

Both

$13.00

Service Code	HCPCS 00604
Min. Negotiated Rate	$5.20
Max. Negotiated Rate	$9.75
Rate for Payer: BCBS Complete	$5.20
Rate for Payer: Cash Price	$10.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$9.75

PR ANES PX ESOPH THYR LARX TRCH&LYMPH NCK NOS 1YR/>

Professional

Both

$6.00

Service Code	HCPCS 00320
Min. Negotiated Rate	$2.40
Max. Negotiated Rate	$4.50
Rate for Payer: BCBS Complete	$2.40
Rate for Payer: Cash Price	$4.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$4.50

PR ANES PX EXTERNAL MIDDLE&INNER EAR W/BX OTOSCOPY

Professional

Both

$4.00

Service Code	HCPCS 00124
Min. Negotiated Rate	$1.60
Max. Negotiated Rate	$3.00
Rate for Payer: BCBS Complete	$1.60
Rate for Payer: Cash Price	$3.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$3.00

PR ANES PX EXTERNAL MID&INNER EAR W/BX TYMPANOTOMY

Professional

Both

$4.00

Service Code	HCPCS 00126
Min. Negotiated Rate	$1.60
Max. Negotiated Rate	$3.00
Rate for Payer: BCBS Complete	$1.60
Rate for Payer: Cash Price	$3.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$3.00

Know your out-of-pocket cost for care.

All Charges