Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

PR ANES TRANSURETHRAL W/URETHROCYSTOSCOPY NOS

Professional

Both

$3.00

Service Code	HCPCS 00910
Min. Negotiated Rate	$1.20
Max. Negotiated Rate	$1.95
Rate for Payer: Aetna Medicare	$1.50
Rate for Payer: BCBS Complete	$1.20
Rate for Payer: Cash Price	$2.40
Rate for Payer: Priority Health Cigna Priority Health	$1.95

PR ANES TRANSVENOUS INSJ/REPLACEMENT PACING CVDFB

Professional

Both

$7.00

Service Code	HCPCS 00534
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$4.55
Rate for Payer: Aetna Medicare	$3.50
Rate for Payer: BCBS Complete	$2.80
Rate for Payer: Cash Price	$5.60
Rate for Payer: Priority Health Cigna Priority Health	$4.55

PR ANES TRURL FRAGMNTJ MANJ&/RMVL URETERAL CALCULUS

Professional

Both

$5.00

Service Code	HCPCS 00918
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$3.25
Rate for Payer: Aetna Medicare	$2.50
Rate for Payer: BCBS Complete	$2.00
Rate for Payer: Cash Price	$4.00
Rate for Payer: Priority Health Cigna Priority Health	$3.25

PR ANES TRURL POST-TRURL RESECTION BLEEDING

Professional

Both

$5.00

Service Code	HCPCS 00916
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$3.25
Rate for Payer: Aetna Medicare	$2.50
Rate for Payer: BCBS Complete	$2.00
Rate for Payer: Cash Price	$4.00
Rate for Payer: Priority Health Cigna Priority Health	$3.25

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	$2.60
Rate for Payer: Aetna Medicare	$2.00
Rate for Payer: BCBS Complete	$1.60
Rate for Payer: Cash Price	$3.20
Rate for Payer: Priority Health Cigna Priority Health	$2.60

PR ANES UPPER 2/3 FEMUR RADICAL RESCECTION

Professional

Both

$8.00

Service Code	HCPCS 01234
Min. Negotiated Rate	$3.20
Max. Negotiated Rate	$5.20
Rate for Payer: Aetna Medicare	$4.00
Rate for Payer: BCBS Complete	$3.20
Rate for Payer: Cash Price	$6.40
Rate for Payer: Priority Health Cigna Priority Health	$5.20

PR ANES UPPER LEG W/BYPASS GRFT FEM ART EMBOLECTOMY

Professional

Both

$6.00

Service Code	HCPCS 01274
Min. Negotiated Rate	$2.40
Max. Negotiated Rate	$3.90
Rate for Payer: Aetna Medicare	$3.00
Rate for Payer: BCBS Complete	$2.40
Rate for Payer: Cash Price	$4.80
Rate for Payer: Priority Health Cigna Priority Health	$3.90

PR ANES UPR ANT ABDL WALL PERCUTANEOUS LIVER BX

Professional

Both

$4.00

Service Code	HCPCS 00702
Min. Negotiated Rate	$1.60
Max. Negotiated Rate	$2.60
Rate for Payer: Aetna Medicare	$2.00
Rate for Payer: BCBS Complete	$1.60
Rate for Payer: Cash Price	$3.20
Rate for Payer: Priority Health Cigna Priority Health	$2.60

PR ANES URGENT HYSTERECTOMY FOLLOWING DELIVERY

Professional

Both

$8.00

Service Code	HCPCS 01962
Min. Negotiated Rate	$3.20
Max. Negotiated Rate	$5.20
Rate for Payer: Aetna Medicare	$4.00
Rate for Payer: BCBS Complete	$3.20
Rate for Payer: Cash Price	$6.40
Rate for Payer: Priority Health Cigna Priority Health	$5.20

PR ANES VASECTOMY UNI/BI INCL OPEN URETHRAL PX

Professional

Both

$3.00

Service Code	HCPCS 00921
Min. Negotiated Rate	$1.20
Max. Negotiated Rate	$1.95
Rate for Payer: Aetna Medicare	$1.50
Rate for Payer: BCBS Complete	$1.20
Rate for Payer: Cash Price	$2.40
Rate for Payer: Priority Health Cigna Priority Health	$1.95

PR ANES VEINS FOREARM WRIST & HAND PHLEBORRHAPHY

Professional

Both

$4.00

Service Code	HCPCS 01852
Min. Negotiated Rate	$1.60
Max. Negotiated Rate	$2.60
Rate for Payer: Aetna Medicare	$2.00
Rate for Payer: BCBS Complete	$1.60
Rate for Payer: Cash Price	$3.20
Rate for Payer: Priority Health Cigna Priority Health	$2.60

PR ANES VEINS LOWER LEG VENOUS THRMBC DIR/W/CATH

Professional

Both

$5.00

Service Code	HCPCS 01522
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$3.25
Rate for Payer: Aetna Medicare	$2.50
Rate for Payer: BCBS Complete	$2.00
Rate for Payer: Cash Price	$4.00
Rate for Payer: Priority Health Cigna Priority Health	$3.25

PR ANES VEINS OF UPPER LEG INCLUDING EXPLORATION

Professional

Both

$3.00

Service Code	HCPCS 01260
Min. Negotiated Rate	$1.20
Max. Negotiated Rate	$1.95
Rate for Payer: Aetna Medicare	$1.50
Rate for Payer: BCBS Complete	$1.20
Rate for Payer: Cash Price	$2.40
Rate for Payer: Priority Health Cigna Priority Health	$1.95

PR ANES VENOUS/LYMPHATIC NOS THER IVNTL RAD NOS

Professional

Both

$5.00

Service Code	HCPCS 01930
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$3.25
Rate for Payer: Aetna Medicare	$2.50
Rate for Payer: BCBS Complete	$2.00
Rate for Payer: Cash Price	$4.00
Rate for Payer: Priority Health Cigna Priority Health	$3.25

PR ANES XTRNL MID & INNER EAR W/BX TYMPANOTOMY

Professional

Both

$4.00

Service Code	HCPCS 00126
Min. Negotiated Rate	$1.60
Max. Negotiated Rate	$2.60
Rate for Payer: Aetna Medicare	$2.00
Rate for Payer: BCBS Complete	$1.60
Rate for Payer: Cash Price	$3.20
Rate for Payer: Priority Health Cigna Priority Health	$2.60

PR ANES XTRPRTL LOWER ABD UR TRACT RENAL DON NFRCT

Professional

Both

$7.00

Service Code	HCPCS 00862
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$4.55
Rate for Payer: Aetna Medicare	$3.50
Rate for Payer: BCBS Complete	$2.80
Rate for Payer: Cash Price	$5.60
Rate for Payer: Priority Health Cigna Priority Health	$4.55

PR ANES XTRPRTL LOWER ABD W/URIN TRACT ADRENLECTOMY

Professional

Both

$10.00

Service Code	HCPCS 00866
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$6.50
Rate for Payer: Aetna Medicare	$5.00
Rate for Payer: BCBS Complete	$4.00
Rate for Payer: Cash Price	$8.00
Rate for Payer: Priority Health Cigna Priority Health	$6.50

PR ANES XTRPRTL LWER ABD W/URINARY TRACT TOT CYSTEC

Professional

Both

$8.00

Service Code	HCPCS 00864
Min. Negotiated Rate	$3.20
Max. Negotiated Rate	$5.20
Rate for Payer: Aetna Medicare	$4.00
Rate for Payer: BCBS Complete	$3.20
Rate for Payer: Cash Price	$6.40
Rate for Payer: Priority Health Cigna Priority Health	$5.20

PR ANES XTRPRTL LWR ABD W/URINARY TRACT RAD PRSTECT

Professional

Both

$7.00

Service Code	HCPCS 00865
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$4.55
Rate for Payer: Aetna Medicare	$3.50
Rate for Payer: BCBS Complete	$2.80
Rate for Payer: Cash Price	$5.60
Rate for Payer: Priority Health Cigna Priority Health	$4.55

PR ANES XTRPRTL LWR ABD W/URIN TRACT CSTOLITHOTOMY

Professional

Both

$5.00

Service Code	HCPCS 00870
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$3.25
Rate for Payer: Aetna Medicare	$2.50
Rate for Payer: BCBS Complete	$2.00
Rate for Payer: Cash Price	$4.00
Rate for Payer: Priority Health Cigna Priority Health	$3.25

PR ANES XTRPRTL LWR ABD W/URIN TRACT RENAL TRANSPL

Professional

Both

$10.00

Service Code	HCPCS 00868
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$6.50
Rate for Payer: Aetna Medicare	$5.00
Rate for Payer: BCBS Complete	$4.00
Rate for Payer: Cash Price	$8.00
Rate for Payer: Priority Health Cigna Priority Health	$6.50

PR ANKLE CONTROL ORTHO PRE OTS

Professional

Both

$95.00

Service Code	HCPCS L4350
Min. Negotiated Rate	$38.00
Max. Negotiated Rate	$167.86
Rate for Payer: Aetna Commercial	$156.20
Rate for Payer: Aetna Medicare	$116.57
Rate for Payer: BCBS Complete	$38.00
Rate for Payer: BCBS MAPPO	$116.57
Rate for Payer: BCN Medicare Advantage	$116.57
Rate for Payer: Cash Price	$76.00
Rate for Payer: Cash Price	$76.00
Rate for Payer: Cofinity Commercial	$167.86
Rate for Payer: Cofinity Commercial	$156.20
Rate for Payer: Health Alliance Plan Medicare Advantage	$116.57
Rate for Payer: Healthscope Commercial	$139.88
Rate for Payer: Healthscope Whirlpool	$139.88
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$122.40
Rate for Payer: Nomi Health Commercial	$139.88
Rate for Payer: PACE SWMI	$116.57
Rate for Payer: PHP Medicare Advantage	$116.57
Rate for Payer: Priority Health Cigna Priority Health	$61.75
Rate for Payer: Priority Health Medicare	$116.57
Rate for Payer: UHC Dual Complete DSNP	$116.57
Rate for Payer: UHC Medicare Advantage	$116.57
Rate for Payer: UHCCP DNSP	$116.57

PR ANKLE DISARTICULATION

Professional

Both

$1,336.00

Service Code	HCPCS 27889
Min. Negotiated Rate	$534.40
Max. Negotiated Rate	$890.35
Rate for Payer: Aetna Commercial	$828.52
Rate for Payer: Aetna Medicare	$618.30
Rate for Payer: BCBS Complete	$534.40
Rate for Payer: BCBS MAPPO	$618.30
Rate for Payer: BCN Medicare Advantage	$618.30
Rate for Payer: Cash Price	$1,068.80
Rate for Payer: Cash Price	$1,068.80
Rate for Payer: Cofinity Commercial	$890.35
Rate for Payer: Cofinity Commercial	$828.52
Rate for Payer: Health Alliance Plan Medicare Advantage	$618.30
Rate for Payer: Healthscope Commercial	$741.96
Rate for Payer: Healthscope Whirlpool	$741.96
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$649.22
Rate for Payer: Nomi Health Commercial	$741.96
Rate for Payer: PACE SWMI	$618.30
Rate for Payer: PHP Medicare Advantage	$618.30
Rate for Payer: Priority Health Cigna Priority Health	$868.40
Rate for Payer: Priority Health Medicare	$618.30
Rate for Payer: UHC Dual Complete DSNP	$618.30
Rate for Payer: UHC Medicare Advantage	$618.30
Rate for Payer: UHCCP DNSP	$618.30

PR ANN BREAST EXAM

Professional

Both

$20.00

Service Code	HCPCS S0613
Min. Negotiated Rate	$8.00
Max. Negotiated Rate	$13.00
Rate for Payer: Aetna Medicare	$10.00
Rate for Payer: BCBS Complete	$8.00
Rate for Payer: Cash Price	$16.00
Rate for Payer: Priority Health Cigna Priority Health	$13.00

PR ANNUAL GYNECOLOGICAL EXAMINA

Professional

Both

$81.00

Service Code	HCPCS S0612
Min. Negotiated Rate	$32.40
Max. Negotiated Rate	$52.65
Rate for Payer: Aetna Medicare	$40.50
Rate for Payer: BCBS Complete	$32.40
Rate for Payer: Cash Price	$64.80
Rate for Payer: Priority Health Cigna Priority Health	$52.65

Know your out-of-pocket cost for care.

All Charges