Bronson Lakeview Hospital

All Charges

Charge

Type

Setting

Price

INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION SOLUTION

Facility

$518.38

Service Code	NDC 0517-0375-01
Hospital Charge Code	108702
Hospital Revenue Code	250
Min. Negotiated Rate	$316.16
Max. Negotiated Rate	$466.54
Rate for Payer: Aetna Commercial	$440.62
Rate for Payer: BCBS Trust/PPO	$400.60
Rate for Payer: BCN Commercial	$400.60
Rate for Payer: Cash Price	$414.70
Rate for Payer: Cofinity Commercial	$445.81
Rate for Payer: Encore Health Key Benefits Commercial	$414.70
Rate for Payer: Healthscope Commercial	$466.54
Rate for Payer: Lakeland Regional Health Systems Commercial	$388.78
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$440.62
Rate for Payer: PHP Commercial	$440.62
Rate for Payer: Priority Health Cigna Priority Health	$362.87
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$450.99
Rate for Payer: Priority Health Narrow/Tiered Network	$316.16
Rate for Payer: UHC All Payor (Choice/PPO)	$456.17
Rate for Payer: UHC Core	$432.85
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$388.78

INDOMETHACIN 25 MG CAPSULE

Facility

$420.65

Service Code	NDC 23155-010-01
Hospital Charge Code	3897
Hospital Revenue Code	637
Min. Negotiated Rate	$256.55
Max. Negotiated Rate	$378.58
Rate for Payer: Aetna Commercial	$357.55
Rate for Payer: BCBS Trust/PPO	$325.08
Rate for Payer: BCN Commercial	$325.08
Rate for Payer: Cash Price	$336.52
Rate for Payer: Cofinity Commercial	$361.76
Rate for Payer: Encore Health Key Benefits Commercial	$336.52
Rate for Payer: Healthscope Commercial	$378.58
Rate for Payer: Lakeland Regional Health Systems Commercial	$315.49
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$357.55
Rate for Payer: PHP Commercial	$357.55
Rate for Payer: Priority Health Cigna Priority Health	$294.46
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$365.97
Rate for Payer: Priority Health Narrow/Tiered Network	$256.55
Rate for Payer: UHC All Payor (Choice/PPO)	$370.17
Rate for Payer: UHC Core	$351.24
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$315.49

INDOMETHACIN 25 MG CAPSULE

Facility

$2.35

Service Code	NDC 50268-430-11
Hospital Charge Code	3897
Hospital Revenue Code	637
Min. Negotiated Rate	$1.43
Max. Negotiated Rate	$2.12
Rate for Payer: Aetna Commercial	$2.00
Rate for Payer: BCBS Trust/PPO	$1.82
Rate for Payer: BCN Commercial	$1.82
Rate for Payer: Cash Price	$1.88
Rate for Payer: Cofinity Commercial	$2.02
Rate for Payer: Encore Health Key Benefits Commercial	$1.88
Rate for Payer: Healthscope Commercial	$2.12
Rate for Payer: Lakeland Regional Health Systems Commercial	$1.76
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$2.00
Rate for Payer: PHP Commercial	$2.00
Rate for Payer: Priority Health Cigna Priority Health	$1.64
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2.04
Rate for Payer: Priority Health Narrow/Tiered Network	$1.43
Rate for Payer: UHC All Payor (Choice/PPO)	$2.07
Rate for Payer: UHC Core	$1.96
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$1.76

INDOMETHACIN 25 MG CAPSULE

Facility

$117.33

Service Code	NDC 50268-430-15
Hospital Charge Code	3897
Hospital Revenue Code	637
Min. Negotiated Rate	$71.56
Max. Negotiated Rate	$105.60
Rate for Payer: Aetna Commercial	$99.73
Rate for Payer: BCBS Trust/PPO	$90.67
Rate for Payer: BCN Commercial	$90.67
Rate for Payer: Cash Price	$93.86
Rate for Payer: Cofinity Commercial	$100.90
Rate for Payer: Encore Health Key Benefits Commercial	$93.86
Rate for Payer: Healthscope Commercial	$105.60
Rate for Payer: Lakeland Regional Health Systems Commercial	$88.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$99.73
Rate for Payer: PHP Commercial	$99.73
Rate for Payer: Priority Health Cigna Priority Health	$82.13
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$102.08
Rate for Payer: Priority Health Narrow/Tiered Network	$71.56
Rate for Payer: UHC All Payor (Choice/PPO)	$103.25
Rate for Payer: UHC Core	$97.97
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$88.00

INHALATIONAL SPACING DEVICE

Facility

$29.35

Service Code	NDC 8373-077478
Hospital Charge Code	113188
Hospital Revenue Code	637
Min. Negotiated Rate	$17.90
Max. Negotiated Rate	$26.42
Rate for Payer: Aetna Commercial	$24.95
Rate for Payer: BCBS Trust/PPO	$22.68
Rate for Payer: BCN Commercial	$22.68
Rate for Payer: Cash Price	$23.48
Rate for Payer: Cofinity Commercial	$25.24
Rate for Payer: Encore Health Key Benefits Commercial	$23.48
Rate for Payer: Healthscope Commercial	$26.42
Rate for Payer: Lakeland Regional Health Systems Commercial	$22.01
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$24.95
Rate for Payer: PHP Commercial	$24.95
Rate for Payer: Priority Health Cigna Priority Health	$20.54
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$25.53
Rate for Payer: Priority Health Narrow/Tiered Network	$17.90
Rate for Payer: UHC All Payor (Choice/PPO)	$25.83
Rate for Payer: UHC Core	$24.51
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$22.01

INHALATIONAL SPACING DEVICE

Facility

$39.08

Service Code	NDC 8373747800
Hospital Charge Code	113188
Hospital Revenue Code	637
Min. Negotiated Rate	$23.83
Max. Negotiated Rate	$35.17
Rate for Payer: Aetna Commercial	$33.22
Rate for Payer: BCBS Trust/PPO	$30.20
Rate for Payer: BCN Commercial	$30.20
Rate for Payer: Cash Price	$31.26
Rate for Payer: Cofinity Commercial	$33.61
Rate for Payer: Encore Health Key Benefits Commercial	$31.26
Rate for Payer: Healthscope Commercial	$35.17
Rate for Payer: Lakeland Regional Health Systems Commercial	$29.31
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$33.22
Rate for Payer: PHP Commercial	$33.22
Rate for Payer: Priority Health Cigna Priority Health	$27.36
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$34.00
Rate for Payer: Priority Health Narrow/Tiered Network	$23.83
Rate for Payer: UHC All Payor (Choice/PPO)	$34.39
Rate for Payer: UHC Core	$32.63
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$29.31

INHALER, ASSIST DEVICES, ACCESSORIES

Facility

$25.87

Service Code	NDC 8373081111
Hospital Charge Code	118717
Hospital Revenue Code	637
Min. Negotiated Rate	$15.78
Max. Negotiated Rate	$23.28
Rate for Payer: Aetna Commercial	$21.99
Rate for Payer: BCBS Trust/PPO	$19.99
Rate for Payer: BCN Commercial	$19.99
Rate for Payer: Cash Price	$20.70
Rate for Payer: Cofinity Commercial	$22.25
Rate for Payer: Encore Health Key Benefits Commercial	$20.70
Rate for Payer: Healthscope Commercial	$23.28
Rate for Payer: Lakeland Regional Health Systems Commercial	$19.40
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$21.99
Rate for Payer: PHP Commercial	$21.99
Rate for Payer: Priority Health Cigna Priority Health	$18.11
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$22.51
Rate for Payer: Priority Health Narrow/Tiered Network	$15.78
Rate for Payer: UHC All Payor (Choice/PPO)	$22.77
Rate for Payer: UHC Core	$21.60
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$19.40

INHALER, ASSIST DEVICES, ACCESSORIES

Facility

$24.83

Service Code	NDC 8373081211
Hospital Charge Code	118717
Hospital Revenue Code	637
Min. Negotiated Rate	$15.14
Max. Negotiated Rate	$22.35
Rate for Payer: Aetna Commercial	$21.11
Rate for Payer: BCBS Trust/PPO	$19.19
Rate for Payer: BCN Commercial	$19.19
Rate for Payer: Cash Price	$19.86
Rate for Payer: Cofinity Commercial	$21.35
Rate for Payer: Encore Health Key Benefits Commercial	$19.86
Rate for Payer: Healthscope Commercial	$22.35
Rate for Payer: Lakeland Regional Health Systems Commercial	$18.62
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$21.11
Rate for Payer: PHP Commercial	$21.11
Rate for Payer: Priority Health Cigna Priority Health	$17.38
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$21.60
Rate for Payer: Priority Health Narrow/Tiered Network	$15.14
Rate for Payer: UHC All Payor (Choice/PPO)	$21.85
Rate for Payer: UHC Core	$20.73
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$18.62

INJECTION PROCEDURE FOR SACROILIAC JOINT; PROVISION OF ANESTHETIC, STEROID AND/OR OTHER THERAPEUTIC AGENT, WITH OR WITHOUT ARTHROGRAPHY

Facility

$476.33

Service Code	CPT G0260
Hospital Revenue Code	361
Min. Negotiated Rate	$453.65
Max. Negotiated Rate	$476.33
Rate for Payer: BCBS Complete	$476.33
Rate for Payer: Mclaren Medicaid	$453.65
Rate for Payer: Meridian Medicaid	$476.33
Rate for Payer: Priority Health Choice Medicaid	$453.65

INJECTION PROCEDURE FOR SACROILIAC JOINT; PROVISION OF ANESTHETIC, STEROID AND/OR OTHER THERAPEUTIC AGENT, WITH OR WITHOUT ARTHROGRAPHY

Facility

$476.33

Service Code	CPT G0260
Hospital Revenue Code	360
Min. Negotiated Rate	$453.65
Max. Negotiated Rate	$476.33
Rate for Payer: BCBS Complete	$476.33
Rate for Payer: Mclaren Medicaid	$453.65
Rate for Payer: Meridian Medicaid	$476.33
Rate for Payer: Priority Health Choice Medicaid	$453.65

INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; FEMORAL NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED

Facility

$476.33

Service Code	CPT 64447
Hospital Revenue Code	361
Min. Negotiated Rate	$453.65
Max. Negotiated Rate	$476.33
Rate for Payer: BCBS Complete	$476.33
Rate for Payer: Mclaren Medicaid	$453.65
Rate for Payer: Meridian Medicaid	$476.33
Rate for Payer: Priority Health Choice Medicaid	$453.65

INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; FEMORAL NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED

Facility

$476.33

Service Code	CPT 64447
Hospital Revenue Code	360
Min. Negotiated Rate	$453.65
Max. Negotiated Rate	$476.33
Rate for Payer: BCBS Complete	$476.33
Rate for Payer: Mclaren Medicaid	$453.65
Rate for Payer: Meridian Medicaid	$476.33
Rate for Payer: Priority Health Choice Medicaid	$453.65

INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GENICULAR NERVE BRANCHES, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED

Facility

$476.33

Service Code	CPT 64454
Hospital Revenue Code	360
Min. Negotiated Rate	$453.65
Max. Negotiated Rate	$476.33
Rate for Payer: BCBS Complete	$476.33
Rate for Payer: Mclaren Medicaid	$453.65
Rate for Payer: Meridian Medicaid	$476.33
Rate for Payer: Priority Health Choice Medicaid	$453.65

INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GREATER OCCIPITAL NERVE

Facility

$204.01

Service Code	CPT 64405
Hospital Revenue Code	360
Min. Negotiated Rate	$194.29
Max. Negotiated Rate	$204.01
Rate for Payer: BCBS Complete	$204.01
Rate for Payer: Mclaren Medicaid	$194.29
Rate for Payer: Meridian Medicaid	$204.01
Rate for Payer: Priority Health Choice Medicaid	$194.29

INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Facility

$627.82

Service Code	CPT 64421
Hospital Revenue Code	360
Min. Negotiated Rate	$597.92
Max. Negotiated Rate	$627.82
Rate for Payer: BCBS Complete	$627.82
Rate for Payer: Mclaren Medicaid	$597.92
Rate for Payer: Meridian Medicaid	$627.82
Rate for Payer: Priority Health Choice Medicaid	$597.92

INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, SINGLE LEVEL

Facility

$476.33

Service Code	CPT 64420
Hospital Revenue Code	360
Min. Negotiated Rate	$453.65
Max. Negotiated Rate	$476.33
Rate for Payer: BCBS Complete	$476.33
Rate for Payer: Mclaren Medicaid	$453.65
Rate for Payer: Meridian Medicaid	$476.33
Rate for Payer: Priority Health Choice Medicaid	$453.65

INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, FLUOROSCOPY OR COMPUTED TOMOGRAPHY)

Facility

$476.33

Service Code	CPT 64451
Hospital Revenue Code	360
Min. Negotiated Rate	$453.65
Max. Negotiated Rate	$476.33
Rate for Payer: BCBS Complete	$476.33
Rate for Payer: Mclaren Medicaid	$453.65
Rate for Payer: Meridian Medicaid	$476.33
Rate for Payer: Priority Health Choice Medicaid	$453.65

INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH

Facility

$476.33

Service Code	CPT 64450
Hospital Revenue Code	360
Min. Negotiated Rate	$453.65
Max. Negotiated Rate	$476.33
Rate for Payer: BCBS Complete	$476.33
Rate for Payer: Mclaren Medicaid	$453.65
Rate for Payer: Meridian Medicaid	$476.33
Rate for Payer: Priority Health Choice Medicaid	$453.65

INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; SINGLE LEVEL

Facility

$627.82

Service Code	CPT 64490
Hospital Revenue Code	360
Min. Negotiated Rate	$597.92
Max. Negotiated Rate	$627.82
Rate for Payer: BCBS Complete	$627.82
Rate for Payer: Mclaren Medicaid	$597.92
Rate for Payer: Meridian Medicaid	$627.82
Rate for Payer: Priority Health Choice Medicaid	$597.92

INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SINGLE LEVEL

Facility

$627.82

Service Code	CPT 64493
Hospital Revenue Code	360
Min. Negotiated Rate	$597.92
Max. Negotiated Rate	$627.82
Rate for Payer: BCBS Complete	$627.82
Rate for Payer: Mclaren Medicaid	$597.92
Rate for Payer: Meridian Medicaid	$627.82
Rate for Payer: Priority Health Choice Medicaid	$597.92

INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, LUMBAR OR SACRAL (CAUDAL); WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)

Facility

$476.33

Service Code	CPT 62323
Hospital Revenue Code	360
Min. Negotiated Rate	$453.65
Max. Negotiated Rate	$476.33
Rate for Payer: BCBS Complete	$476.33
Rate for Payer: Mclaren Medicaid	$453.65
Rate for Payer: Meridian Medicaid	$476.33
Rate for Payer: Priority Health Choice Medicaid	$453.65

INJECTION(S), PLATELET RICH PLASMA, ANY SITE, INCLUDING IMAGE GUIDANCE, HARVESTING AND PREPARATION WHEN PERFORMED

Facility

$274.44

Service Code	CPT 0232T
Hospital Revenue Code	360
Min. Negotiated Rate	$261.37
Max. Negotiated Rate	$274.44
Rate for Payer: BCBS Complete	$274.44
Rate for Payer: Mclaren Medicaid	$261.37
Rate for Payer: Meridian Medicaid	$274.44
Rate for Payer: Priority Health Choice Medicaid	$261.37

INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)

Facility

$204.01

Service Code	CPT 20552
Hospital Revenue Code	360
Min. Negotiated Rate	$194.29
Max. Negotiated Rate	$204.01
Rate for Payer: BCBS Complete	$204.01
Rate for Payer: Mclaren Medicaid	$194.29
Rate for Payer: Meridian Medicaid	$204.01
Rate for Payer: Priority Health Choice Medicaid	$194.29

INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES

Facility

$204.01

Service Code	CPT 20553
Hospital Revenue Code	360
Min. Negotiated Rate	$194.29
Max. Negotiated Rate	$204.01
Rate for Payer: BCBS Complete	$204.01
Rate for Payer: Mclaren Medicaid	$194.29
Rate for Payer: Meridian Medicaid	$204.01
Rate for Payer: Priority Health Choice Medicaid	$194.29

INJECTION(S); SINGLE TENDON ORIGIN/INSERTION

Facility

$204.01

Service Code	CPT 20551
Hospital Revenue Code	360
Min. Negotiated Rate	$194.29
Max. Negotiated Rate	$204.01
Rate for Payer: BCBS Complete	$204.01
Rate for Payer: Mclaren Medicaid	$194.29
Rate for Payer: Meridian Medicaid	$204.01
Rate for Payer: Priority Health Choice Medicaid	$194.29

Know your out-of-pocket cost for care.

All Charges