Bronson Lakeview Hospital

All Charges

Charge

Type

Setting

Price

PR ADJT TIS TRNSFR/REARGMT SCALP/ARM/LEG 10 SQ CM/<

Professional

Both

$1,204.00

Service Code	HCPCS 14020
Min. Negotiated Rate	$321.84
Max. Negotiated Rate	$903.00
Rate for Payer: Aetna Commercial	$598.90
Rate for Payer: Aetna Medicare	$602.00
Rate for Payer: BCBS Complete	$337.93
Rate for Payer: BCN Commercial	$857.02
Rate for Payer: Cash Price	$963.20
Rate for Payer: Cash Price	$963.20
Rate for Payer: Mclaren Medicaid	$321.84
Rate for Payer: Meridian Medicaid	$337.93
Rate for Payer: Opus (Opus Packaging Group) HMA	$903.00
Rate for Payer: Priority Health Choice Medicaid	$321.84
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$784.40
Rate for Payer: Priority Health Narrow/Tiered Network	$784.40
Rate for Payer: UHC Medicaid	$321.84
Rate for Payer: UHCCP Medicaid	$321.84

PR ADJT TIS TRNSFR/REARRGMT E/N/E/L DFCT 10 SQ CM/<

Professional

Both

$2,129.00

Service Code	HCPCS 14060
Min. Negotiated Rate	$365.72
Max. Negotiated Rate	$1,596.75
Rate for Payer: Aetna Commercial	$705.60
Rate for Payer: Aetna Medicare	$1,064.50
Rate for Payer: BCBS Complete	$384.01
Rate for Payer: BCN Commercial	$1,001.94
Rate for Payer: Cash Price	$1,703.20
Rate for Payer: Cash Price	$1,703.20
Rate for Payer: Mclaren Medicaid	$365.72
Rate for Payer: Meridian Medicaid	$384.01
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,596.75
Rate for Payer: Priority Health Choice Medicaid	$365.72
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$917.03
Rate for Payer: Priority Health Narrow/Tiered Network	$917.03
Rate for Payer: UHC Medicaid	$365.72
Rate for Payer: UHCCP Medicaid	$365.72

PR ADJT TIS TRNS/REARGMT F/C/C/M/N/A/G/H/F 10SQCM/<

Facility

$1,338.00

Service Code	CPT 14040
Hospital Charge Code	14040
Hospital Revenue Code	960
Min. Negotiated Rate	$931.25
Max. Negotiated Rate	$1,204.20
Rate for Payer: Aetna Commercial	$1,137.30
Rate for Payer: BCBS Trust/PPO	$1,105.05
Rate for Payer: BCN Commercial	$1,105.05
Rate for Payer: Cash Price	$1,070.40
Rate for Payer: Cofinity Commercial	$1,150.68
Rate for Payer: Encore Health Key Benefits Commercial	$1,070.40
Rate for Payer: Healthscope Commercial	$1,204.20
Rate for Payer: Lakeland Regional Health Systems Commercial	$1,003.50
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,137.30
Rate for Payer: Nomi Health Commercial	$1,097.16
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,003.50
Rate for Payer: PHP Commercial	$1,137.30
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$1,164.06
Rate for Payer: Priority Health Narrow/Tiered Network	$931.25
Rate for Payer: UHC Core	$1,117.23
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$1,003.50

PR ADJT TIS TRNS/REARGMT F/C/C/M/N/A/G/H/F 10SQCM/<

Professional

Both

$1,338.00

Service Code	HCPCS 14040
Min. Negotiated Rate	$348.26
Max. Negotiated Rate	$1,003.50
Rate for Payer: Aetna Commercial	$663.21
Rate for Payer: Aetna Medicare	$669.00
Rate for Payer: BCBS Complete	$365.67
Rate for Payer: BCN Commercial	$941.18
Rate for Payer: Cash Price	$1,070.40
Rate for Payer: Cash Price	$1,070.40
Rate for Payer: Mclaren Medicaid	$348.26
Rate for Payer: Meridian Medicaid	$365.67
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,003.50
Rate for Payer: Priority Health Choice Medicaid	$348.26
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$861.43
Rate for Payer: Priority Health Narrow/Tiered Network	$861.43
Rate for Payer: UHC Medicaid	$348.26
Rate for Payer: UHCCP Medicaid	$348.26

PR ADJT TIS TRNS/REARGMT F/C/C/M/N/A/G/H/F 10SQCM/<

Facility

$1,338.00

Service Code	CPT 14040
Hospital Charge Code	14040
Hospital Revenue Code	960
Min. Negotiated Rate	$235.89
Max. Negotiated Rate	$1,204.20
Rate for Payer: Aetna Commercial	$1,137.30
Rate for Payer: Aetna Medicare	$347.88
Rate for Payer: Allen County Amish Medical Aid Commercial	$418.12
Rate for Payer: Amish Plain Church Group Commercial	$418.12
Rate for Payer: BCBS Complete	$247.66
Rate for Payer: BCBS MAPPO	$334.50
Rate for Payer: BCBS Trust/PPO	$1,099.97
Rate for Payer: BCN Commercial	$1,099.97
Rate for Payer: BCN Medicare Advantage	$334.50
Rate for Payer: Cash Price	$1,070.40
Rate for Payer: Cofinity Commercial	$1,150.68
Rate for Payer: Encore Health Key Benefits Commercial	$1,070.40
Rate for Payer: Health Alliance Plan Medicare Advantage	$334.50
Rate for Payer: Healthscope Commercial	$1,204.20
Rate for Payer: Lakeland Regional Health Systems Commercial	$1,003.50
Rate for Payer: Mclaren Medicaid	$235.89
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$351.23
Rate for Payer: Meridian Medicaid	$247.66
Rate for Payer: MI Amish Medical Board Commercial	$384.68
Rate for Payer: Molina Medicare/Medicaid	$367.95
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,137.30
Rate for Payer: Nomi Health Commercial	$1,097.16
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,003.50
Rate for Payer: PACE Senior Care Partners	$317.77
Rate for Payer: PACE SWMI	$334.50
Rate for Payer: PHP Commercial	$1,137.30
Rate for Payer: PHP Medicare Advantage	$334.50
Rate for Payer: Priority Health Choice Medicaid	$235.89
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$1,164.06
Rate for Payer: Priority Health Medicare	$337.85
Rate for Payer: Priority Health Narrow/Tiered Network	$931.25
Rate for Payer: Railroad Medicare Medicare	$334.50
Rate for Payer: UHC Core	$1,117.23
Rate for Payer: UHC Exchange	$334.50
Rate for Payer: UHC Medicaid	$235.89
Rate for Payer: UHC Medicare Advantage	$334.50
Rate for Payer: UHCCP Medicaid	$235.89
Rate for Payer: VA VA	$334.50
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$1,003.50

PR ADJT TIS TRNS/REARGMT F/C/C/M/N/A/G/H/F 10SQCM/<

Professional

Both

$1,338.00

Service Code	HCPCS 14040
Hospital Charge Code	14040
Min. Negotiated Rate	$348.26
Max. Negotiated Rate	$1,003.50
Rate for Payer: Aetna Commercial	$663.21
Rate for Payer: Aetna Medicare	$669.00
Rate for Payer: BCBS Complete	$365.67
Rate for Payer: BCN Commercial	$941.18
Rate for Payer: Cash Price	$1,070.40
Rate for Payer: Cash Price	$1,070.40
Rate for Payer: Mclaren Medicaid	$348.26
Rate for Payer: Meridian Medicaid	$365.67
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,003.50
Rate for Payer: Priority Health Choice Medicaid	$348.26
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$861.43
Rate for Payer: Priority Health Narrow/Tiered Network	$861.43
Rate for Payer: UHC Medicaid	$348.26
Rate for Payer: UHCCP Medicaid	$348.26

PR ADJUSTMENT GASTRIC BAND

Professional

Both

$118.00

Service Code	HCPCS S2083
Min. Negotiated Rate	$59.00
Max. Negotiated Rate	$109.78
Rate for Payer: Aetna Commercial	$67.62
Rate for Payer: Aetna Medicare	$59.00
Rate for Payer: BCN Commercial	$109.78
Rate for Payer: Cash Price	$94.40
Rate for Payer: Cash Price	$94.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$88.50

PR ADJUSTMENT/REVJ XTRNL FIXATION SYSTEM REQ ANES

Professional

Both

$1,056.00

Service Code	HCPCS 20693
Min. Negotiated Rate	$274.13
Max. Negotiated Rate	$792.00
Rate for Payer: Aetna Commercial	$588.13
Rate for Payer: Aetna Medicare	$528.00
Rate for Payer: BCBS Complete	$287.84
Rate for Payer: BCN Commercial	$687.71
Rate for Payer: Cash Price	$844.80
Rate for Payer: Cash Price	$844.80
Rate for Payer: Mclaren Medicaid	$274.13
Rate for Payer: Meridian Medicaid	$287.84
Rate for Payer: Opus (Opus Packaging Group) HMA	$792.00
Rate for Payer: Priority Health Choice Medicaid	$274.13
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$735.15
Rate for Payer: Priority Health Narrow/Tiered Network	$735.15
Rate for Payer: UHC Medicaid	$274.13
Rate for Payer: UHCCP Medicaid	$274.13

PR ADMIN HEPATITIS B VACCINE

Professional

Both

$31.00

Service Code	HCPCS G0010
Min. Negotiated Rate	$10.00
Max. Negotiated Rate	$47.76
Rate for Payer: Aetna Commercial	$10.00
Rate for Payer: Aetna Medicare	$15.50
Rate for Payer: BCN Commercial	$22.11
Rate for Payer: Cash Price	$24.80
Rate for Payer: Cash Price	$24.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$23.25
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$47.76
Rate for Payer: Priority Health Narrow/Tiered Network	$47.76

PR ADMIN INFLUENZA VIRUS VAC

Professional

Both

$34.00

Service Code	HCPCS G0008
Min. Negotiated Rate	$10.00
Max. Negotiated Rate	$47.76
Rate for Payer: Aetna Commercial	$10.00
Rate for Payer: Aetna Medicare	$17.00
Rate for Payer: BCN Commercial	$22.11
Rate for Payer: Cash Price	$27.20
Rate for Payer: Cash Price	$27.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$25.50
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$47.76
Rate for Payer: Priority Health Narrow/Tiered Network	$47.76

PR ADMIN PNEUMOCOCCAL VACCINE

Professional

Both

$34.00

Service Code	HCPCS G0009
Min. Negotiated Rate	$10.00
Max. Negotiated Rate	$47.76
Rate for Payer: Aetna Commercial	$10.00
Rate for Payer: Aetna Medicare	$17.00
Rate for Payer: BCN Commercial	$22.11
Rate for Payer: Cash Price	$27.20
Rate for Payer: Cash Price	$27.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$25.50
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$47.76
Rate for Payer: Priority Health Narrow/Tiered Network	$47.76

PR ADMN RSV MONOC ANTB SEASONAL DOS IM CNSL PHY/QHP

Professional

Both

$88.00

Service Code	HCPCS 96380
Min. Negotiated Rate	$12.00
Max. Negotiated Rate	$66.00
Rate for Payer: Aetna Commercial	$12.00
Rate for Payer: Aetna Medicare	$44.00
Rate for Payer: BCN Commercial	$27.07
Rate for Payer: Cash Price	$70.40
Rate for Payer: Cash Price	$70.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$66.00
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$31.69
Rate for Payer: Priority Health Narrow/Tiered Network	$31.69

PR ADMN RSV MONOCLONAL ANTB SEASONAL DOSE IM NJX

Professional

Both

$88.00

Service Code	HCPCS 96381
Min. Negotiated Rate	$12.00
Max. Negotiated Rate	$66.00
Rate for Payer: Aetna Commercial	$12.00
Rate for Payer: Aetna Medicare	$44.00
Rate for Payer: BCN Commercial	$27.07
Rate for Payer: Cash Price	$70.40
Rate for Payer: Cash Price	$70.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$66.00
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$27.09
Rate for Payer: Priority Health Narrow/Tiered Network	$27.09

PR ADRENALECTOMY EXPL W/EXC RETROPERTINEAL TUMOR

Professional

Both

$4,570.00

Service Code	HCPCS 60545
Min. Negotiated Rate	$748.91
Max. Negotiated Rate	$3,427.50
Rate for Payer: Aetna Commercial	$1,609.79
Rate for Payer: Aetna Medicare	$2,285.00
Rate for Payer: BCBS Complete	$786.36
Rate for Payer: BCN Commercial	$1,865.93
Rate for Payer: Cash Price	$3,656.00
Rate for Payer: Cash Price	$3,656.00
Rate for Payer: Mclaren Medicaid	$748.91
Rate for Payer: Meridian Medicaid	$786.36
Rate for Payer: Opus (Opus Packaging Group) HMA	$3,427.50
Rate for Payer: Priority Health Choice Medicaid	$748.91
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$2,023.30
Rate for Payer: Priority Health Narrow/Tiered Network	$2,023.30
Rate for Payer: UHC Medicaid	$748.91
Rate for Payer: UHCCP Medicaid	$748.91

PR ADRENALECTOMY W/EXPL W/WO BX ABDL/LMBR/DRSAL SPX

Professional

Both

$3,470.00

Service Code	HCPCS 60540
Min. Negotiated Rate	$644.75
Max. Negotiated Rate	$2,602.50
Rate for Payer: Aetna Commercial	$1,390.93
Rate for Payer: Aetna Medicare	$1,735.00
Rate for Payer: BCBS Complete	$676.99
Rate for Payer: BCN Commercial	$1,619.93
Rate for Payer: Cash Price	$2,776.00
Rate for Payer: Cash Price	$2,776.00
Rate for Payer: Mclaren Medicaid	$644.75
Rate for Payer: Meridian Medicaid	$676.99
Rate for Payer: Opus (Opus Packaging Group) HMA	$2,602.50
Rate for Payer: Priority Health Choice Medicaid	$644.75
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$1,756.55
Rate for Payer: Priority Health Narrow/Tiered Network	$1,756.55
Rate for Payer: UHC Medicaid	$644.75
Rate for Payer: UHCCP Medicaid	$644.75

PR ADRENALIN EPINEPHRINE INJECT

Professional

Both

$5.00

Service Code	HCPCS J0171
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$3.75
Rate for Payer: Aetna Commercial	$0.77
Rate for Payer: Aetna Medicare	$2.50
Rate for Payer: BCBS Complete	$2.00
Rate for Payer: BCN Commercial	$0.08
Rate for Payer: Cash Price	$4.00
Rate for Payer: Cash Price	$4.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$3.75

PR ADVANCE CARE PLANNING EA ADDL 30 MINS

Professional

Both

$84.00

Service Code	HCPCS 99498
Min. Negotiated Rate	$40.47
Max. Negotiated Rate	$92.33
Rate for Payer: Aetna Commercial	$72.67
Rate for Payer: Aetna Medicare	$42.00
Rate for Payer: BCBS Complete	$42.49
Rate for Payer: BCN Commercial	$77.01
Rate for Payer: Cash Price	$67.20
Rate for Payer: Cash Price	$67.20
Rate for Payer: Mclaren Medicaid	$40.47
Rate for Payer: Meridian Medicaid	$42.49
Rate for Payer: Opus (Opus Packaging Group) HMA	$63.00
Rate for Payer: Priority Health Choice Medicaid	$40.47
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$92.33
Rate for Payer: Priority Health Narrow/Tiered Network	$92.33
Rate for Payer: UHC Medicaid	$40.47
Rate for Payer: UHCCP Medicaid	$40.47

PR ADVANCE CARE PLANNING FIRST 30 MINS

Professional

Both

$106.00

Service Code	HCPCS 99497
Min. Negotiated Rate	$41.96
Max. Negotiated Rate	$97.57
Rate for Payer: Aetna Commercial	$77.18
Rate for Payer: Aetna Medicare	$53.00
Rate for Payer: BCBS Complete	$44.06
Rate for Payer: BCN Commercial	$81.36
Rate for Payer: Cash Price	$84.80
Rate for Payer: Cash Price	$84.80
Rate for Payer: Mclaren Medicaid	$41.96
Rate for Payer: Meridian Medicaid	$44.06
Rate for Payer: Opus (Opus Packaging Group) HMA	$79.50
Rate for Payer: Priority Health Choice Medicaid	$41.96
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$97.57
Rate for Payer: Priority Health Narrow/Tiered Network	$97.57
Rate for Payer: UHC Medicaid	$41.96
Rate for Payer: UHCCP Medicaid	$41.96

PR AEP HEARING STATUS DETER BROADBAND STIMULI I&R

Professional

Both

$166.00

Service Code	HCPCS 92651
Min. Negotiated Rate	$83.00
Max. Negotiated Rate	$124.50
Rate for Payer: Aetna Commercial	$96.89
Rate for Payer: Aetna Medicare	$83.00
Rate for Payer: BCN Commercial	$118.03
Rate for Payer: Cash Price	$132.80
Rate for Payer: Cash Price	$132.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$124.50
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$108.84
Rate for Payer: Priority Health Narrow/Tiered Network	$108.84

PR AEP NEURODIAGNOSTIC INTERPRETATION AND REPORT

Professional

Both

$174.00

Service Code	HCPCS 92653
Min. Negotiated Rate	$87.00
Max. Negotiated Rate	$130.50
Rate for Payer: Aetna Commercial	$93.15
Rate for Payer: Aetna Medicare	$87.00
Rate for Payer: BCN Commercial	$121.01
Rate for Payer: Cash Price	$139.20
Rate for Payer: Cash Price	$139.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$130.50
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$111.59
Rate for Payer: Priority Health Narrow/Tiered Network	$111.59

PR AEP SCR AUDITORY POTENTIAL W/STIMULI AUTO ALYS

Professional

Both

$57.00

Service Code	HCPCS 92650
Min. Negotiated Rate	$13.63
Max. Negotiated Rate	$42.75
Rate for Payer: Aetna Commercial	$30.47
Rate for Payer: Aetna Medicare	$28.50
Rate for Payer: BCBS Complete	$14.31
Rate for Payer: BCN Commercial	$39.34
Rate for Payer: Cash Price	$45.60
Rate for Payer: Cash Price	$45.60
Rate for Payer: Mclaren Medicaid	$13.63
Rate for Payer: Meridian Medicaid	$14.31
Rate for Payer: Opus (Opus Packaging Group) HMA	$42.75
Rate for Payer: Priority Health Choice Medicaid	$13.63
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$36.27
Rate for Payer: Priority Health Narrow/Tiered Network	$36.27
Rate for Payer: UHC Medicaid	$13.63
Rate for Payer: UHCCP Medicaid	$13.63

PR AEP THRESHOLD ESTIMATION MLT FREQUENCIES I&R

Professional

Both

$240.00

Service Code	HCPCS 92652
Min. Negotiated Rate	$120.00
Max. Negotiated Rate	$180.00
Rate for Payer: Aetna Commercial	$127.57
Rate for Payer: Aetna Medicare	$120.00
Rate for Payer: BCN Commercial	$161.85
Rate for Payer: Cash Price	$192.00
Rate for Payer: Cash Price	$192.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$180.00
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$149.26
Rate for Payer: Priority Health Narrow/Tiered Network	$149.26

PR AFO ANKLE GAUNTLET PRE OTS

Professional

Both

$75.00

Service Code	HCPCS L1902
Min. Negotiated Rate	$30.00
Max. Negotiated Rate	$87.83
Rate for Payer: Aetna Commercial	$44.96
Rate for Payer: Aetna Medicare	$37.50
Rate for Payer: BCBS Complete	$30.00
Rate for Payer: BCN Commercial	$87.83
Rate for Payer: Cash Price	$60.00
Rate for Payer: Cash Price	$60.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$56.25

PR AFO MULTILIG ANK SUP PRE OTS

Professional

Both

$113.00

Service Code	HCPCS L1906
Min. Negotiated Rate	$45.20
Max. Negotiated Rate	$132.31
Rate for Payer: Aetna Commercial	$67.73
Rate for Payer: Aetna Medicare	$56.50
Rate for Payer: BCBS Complete	$45.20
Rate for Payer: BCN Commercial	$132.31
Rate for Payer: Cash Price	$90.40
Rate for Payer: Cash Price	$90.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$84.75

PR AIIV4 VACC INACTIVATED PRSRV FR 0.5ML DOS IM USE

Professional

Both

$187.00

Service Code	HCPCS 90694
Min. Negotiated Rate	$67.98
Max. Negotiated Rate	$140.25
Rate for Payer: Aetna Commercial	$77.36
Rate for Payer: Aetna Medicare	$93.50
Rate for Payer: BCBS Trust/PPO	$67.98
Rate for Payer: BCN Commercial	$77.36
Rate for Payer: Cash Price	$149.60
Rate for Payer: Cash Price	$149.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$140.25

Know your out-of-pocket cost for care.

All Charges