Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

PR ANESTHESIA PX ARTERIES FOREARM WRIST&HAND NOS

Professional

Both

$6.00

Service Code	HCPCS 01840
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 ANESTHESIA PX ARTERIES LWR LEG W/BYPASS GRF NOS

Professional

Both

$8.00

Service Code	HCPCS 01500
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 ANESTHESIA PX ARTERIES SHOULDER&AXILLA NOS

Professional

Both

$6.00

Service Code	HCPCS 01650
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 ANESTHESIA PX ARTERIES UPPER ARM&ELBOW NOS

Professional

Both

$6.00

Service Code	HCPCS 01770
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 ANESTHESIA PX ARTERIES UPPER LEG NOS

Professional

Both

$8.00

Service Code	HCPCS 01270
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 ANESTHESIA PX ARTERIES UPR ARM&ELBW EMBOLECTOMY

Professional

Both

$6.00

Service Code	HCPCS 01772
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 ANESTHESIA PX CERVICAL SPINE & CORD NOS

Professional

Both

$10.00

Service Code	HCPCS 00600
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 ANESTHESIA PX CLAVICLE AND SCAPULA NOS

Professional

Both

$5.00

Service Code	HCPCS 00450
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 ANESTHESIA PX CLAVICLE & SCAPULA BIOPSY CLAVICLE

Professional

Both

$3.00

Service Code	HCPCS 00454
Min. Negotiated Rate	$1.20
Max. Negotiated Rate	$2.25
Rate for Payer: BCBS Complete	$1.20
Rate for Payer: Cash Price	$2.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$2.25

PR ANESTHESIA PX INTEG SYS RAD/MODIFIED RAD BREAST

Professional

Both

$5.00

Service Code	HCPCS 00404
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 ANESTHESIA PX INTEG SYS RECONSTRUCTIVE PX BREAST

Professional

Both

$5.00

Service Code	HCPCS 00402
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 ANESTHESIA PX INVOLVING PLASTIC REPAIR CLEFT LIP

Professional

Both

$6.00

Service Code	HCPCS 00102
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 ANESTHESIA PX LOWER ANTERIOR ABDOMINAL WALL NOS

Professional

Both

$4.00

Service Code	HCPCS 00800
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 ANESTHESIA PX LOWER POSTERIOR ABDOMINAL WALL

Professional

Both

$5.00

Service Code	HCPCS 00820
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 ANESTHESIA PX LUMBAR REGION LUMBAR SYMPATHECTOMY

Professional

Both

$7.00

Service Code	HCPCS 00632
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 ANESTHESIA PX MAJOR LOWER ABDOMINAL VESSELS NOS

Professional

Both

$15.00

Service Code	HCPCS 00880
Min. Negotiated Rate	$6.00
Max. Negotiated Rate	$11.25
Rate for Payer: BCBS Complete	$6.00
Rate for Payer: Cash Price	$12.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$11.25

PR ANESTHESIA PX MALE GENITALIA NOS

Professional

Both

$3.00

Service Code	HCPCS 00920
Min. Negotiated Rate	$1.20
Max. Negotiated Rate	$2.25
Rate for Payer: BCBS Complete	$1.20
Rate for Payer: Cash Price	$2.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$2.25

PR ANESTHESIA PX MALE GENITALIA SEMINAL VESICLES

Professional

Both

$6.00

Service Code	HCPCS 00922
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 ANESTHESIA PX ON EYE CORNEAL TRANSPLANT

Professional

Both

$6.00

Service Code	HCPCS 00144
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 ANESTHESIA PX ON EYE IRIDECTOMY

Professional

Both

$4.00

Service Code	HCPCS 00147
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 ANESTHESIA PX ON EYE LENS SURGERY

Professional

Both

$4.00

Service Code	HCPCS 00142
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 ANESTHESIA PX ON EYE NOT OTHERWISE SPECIFIED

Professional

Both

$5.00

Service Code	HCPCS 00140
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 ANESTHESIA PX ON EYE OPHTHALMOSCOPY

Professional

Both

$4.00

Service Code	HCPCS 00148
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 ANESTHESIA PX ON EYE VITREORETINAL SURGERY

Professional

Both

$6.00

Service Code	HCPCS 00145
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 ANESTHESIA PX ON FACIAL BONES OR SKULL NOS

Professional

Both

$5.00

Service Code	HCPCS 00190
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

Know your out-of-pocket cost for care.

All Charges