Bronson Lakeview Hospital

All Charges

Charge

Type

Setting

Price

PR CBHC CONSULT FEE $300

Professional

Both

$306.00

Service Code	HCPCS 00585
Hospital Revenue Code	990
Min. Negotiated Rate	$122.40
Max. Negotiated Rate	$198.90
Rate for Payer: Aetna Medicare	$153.00
Rate for Payer: BCBS Complete	$122.40
Rate for Payer: Cash Price	$244.80
Rate for Payer: Priority Health Cigna Priority Health	$198.90

PR CBHC IN HOUSE REPAIR

Professional

Both

$36.00

Service Code	HCPCS 00580
Hospital Revenue Code	990
Min. Negotiated Rate	$14.40
Max. Negotiated Rate	$23.40
Rate for Payer: Aetna Medicare	$18.00
Rate for Payer: BCBS Complete	$14.40
Rate for Payer: Cash Price	$28.80
Rate for Payer: Priority Health Cigna Priority Health	$23.40

PR CBHC IN-HOUSE REPAIR

Professional

Both

$27.00

Service Code	HCPCS 00590
Hospital Revenue Code	990
Min. Negotiated Rate	$10.80
Max. Negotiated Rate	$17.55
Rate for Payer: Aetna Medicare	$13.50
Rate for Payer: BCBS Complete	$10.80
Rate for Payer: Cash Price	$21.60
Rate for Payer: Priority Health Cigna Priority Health	$17.55

PR CBHC LOSS AND DAMAGE FEE

Professional

Both

$281.00

Service Code	HCPCS 00581
Hospital Revenue Code	990
Min. Negotiated Rate	$112.40
Max. Negotiated Rate	$182.65
Rate for Payer: Aetna Medicare	$140.50
Rate for Payer: BCBS Complete	$112.40
Rate for Payer: Cash Price	$224.80
Rate for Payer: Priority Health Cigna Priority Health	$182.65

PR CBHC MAILING CHARGE

Professional

Both

$46.00

Service Code	HCPCS 00584
Hospital Revenue Code	990
Min. Negotiated Rate	$18.40
Max. Negotiated Rate	$29.90
Rate for Payer: Aetna Medicare	$23.00
Rate for Payer: BCBS Complete	$18.40
Rate for Payer: Cash Price	$36.80
Rate for Payer: Priority Health Cigna Priority Health	$29.90

PR CBHC RECASE BTE

Professional

Both

$61.00

Service Code	HCPCS 00582
Hospital Revenue Code	990
Min. Negotiated Rate	$24.40
Max. Negotiated Rate	$39.65
Rate for Payer: Aetna Medicare	$30.50
Rate for Payer: BCBS Complete	$24.40
Rate for Payer: Cash Price	$48.80
Rate for Payer: Priority Health Cigna Priority Health	$39.65

PR CBHC RECASE ITE

Professional

Both

$179.00

Service Code	HCPCS 00583
Hospital Revenue Code	990
Min. Negotiated Rate	$71.60
Max. Negotiated Rate	$116.35
Rate for Payer: Aetna Medicare	$89.50
Rate for Payer: BCBS Complete	$71.60
Rate for Payer: Cash Price	$143.20
Rate for Payer: Priority Health Cigna Priority Health	$116.35

PR CBHC REPAIR 5 YRS AND OLDER

Professional

Both

$434.00

Service Code	HCPCS 00589
Hospital Revenue Code	990
Min. Negotiated Rate	$173.60
Max. Negotiated Rate	$282.10
Rate for Payer: Aetna Medicare	$217.00
Rate for Payer: BCBS Complete	$173.60
Rate for Payer: Cash Price	$347.20
Rate for Payer: Priority Health Cigna Priority Health	$282.10

PR CBHC REPAIR DIGITAL/CIC

Professional

Both

$306.00

Service Code	HCPCS 00588
Hospital Revenue Code	990
Min. Negotiated Rate	$122.40
Max. Negotiated Rate	$198.90
Rate for Payer: Aetna Medicare	$153.00
Rate for Payer: BCBS Complete	$122.40
Rate for Payer: Cash Price	$244.80
Rate for Payer: Priority Health Cigna Priority Health	$198.90

PR CBHC REPAIR RECEIVER

Professional

Both

$128.00

Service Code	HCPCS 00587
Hospital Revenue Code	990
Min. Negotiated Rate	$51.20
Max. Negotiated Rate	$83.20
Rate for Payer: Aetna Medicare	$64.00
Rate for Payer: BCBS Complete	$51.20
Rate for Payer: Cash Price	$102.40
Rate for Payer: Priority Health Cigna Priority Health	$83.20

PR CCIIV3 VACCINE ABX FREE 0.5 ML FOR IM USE

Professional

Both

$43.00

Service Code	HCPCS 90661
Min. Negotiated Rate	$17.20
Max. Negotiated Rate	$71.28
Rate for Payer: Aetna Commercial	$66.33
Rate for Payer: Aetna Medicare	$51.48
Rate for Payer: BCBS Complete	$17.20
Rate for Payer: BCBS MAPPO	$49.50
Rate for Payer: BCN Medicare Advantage	$49.50
Rate for Payer: Cash Price	$34.40
Rate for Payer: Cash Price	$34.40
Rate for Payer: Cofinity Commercial	$66.33
Rate for Payer: Cofinity Commercial	$71.28
Rate for Payer: Health Alliance Plan Medicare Advantage	$49.50
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$51.98
Rate for Payer: Nomi Health Commercial	$59.40
Rate for Payer: PACE SWMI	$49.50
Rate for Payer: PHP Medicare Advantage	$49.50
Rate for Payer: Priority Health Cigna Priority Health	$27.95
Rate for Payer: Priority Health Medicare	$49.99
Rate for Payer: UHC All Payor (Choice/PPO)	$49.50
Rate for Payer: UHC Dual Complete DSNP	$49.50
Rate for Payer: UHC Exchange	$49.50
Rate for Payer: UHC Medicare Advantage	$49.50

PR CCIIV4 VACCINE ANTIBIOTIC FREE 0.5 ML DOS IM USE

Professional

Both

$68.00

Service Code	HCPCS 90756
Min. Negotiated Rate	$27.20
Max. Negotiated Rate	$44.20
Rate for Payer: Aetna Medicare	$34.00
Rate for Payer: BCBS Complete	$27.20
Rate for Payer: Cash Price	$54.40
Rate for Payer: Priority Health Cigna Priority Health	$44.20

PR CCIIV4 VACCINE PRESERVATIVE FREE 0.5 ML IM USE

Professional

Both

$73.00

Service Code	HCPCS 90674
Min. Negotiated Rate	$29.20
Max. Negotiated Rate	$47.45
Rate for Payer: Aetna Medicare	$36.50
Rate for Payer: BCBS Complete	$29.20
Rate for Payer: Cash Price	$58.40
Rate for Payer: Priority Health Cigna Priority Health	$47.45

PR CCM/BHI BY RHC/FQHC 20MIN MO

Professional

Both

$251.00

Service Code	HCPCS G0511
Min. Negotiated Rate	$100.40
Max. Negotiated Rate	$163.15
Rate for Payer: Aetna Medicare	$125.50
Rate for Payer: BCBS Complete	$100.40
Rate for Payer: Cash Price	$200.80
Rate for Payer: Priority Health Cigna Priority Health	$163.15

PR CEFTRIAXONE SODIUM INJECTION

Professional

Both

$20.00

Service Code	HCPCS J0696
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$13.00
Rate for Payer: Aetna Commercial	$0.58
Rate for Payer: Aetna Medicare	$0.45
Rate for Payer: BCBS Complete	$8.00
Rate for Payer: BCBS MAPPO	$0.43
Rate for Payer: BCN Medicare Advantage	$0.43
Rate for Payer: Cash Price	$16.00
Rate for Payer: Cash Price	$16.00
Rate for Payer: Cofinity Commercial	$0.62
Rate for Payer: Cofinity Commercial	$0.58
Rate for Payer: Health Alliance Plan Medicare Advantage	$0.43
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$0.45
Rate for Payer: Nomi Health Commercial	$0.52
Rate for Payer: PACE SWMI	$0.43
Rate for Payer: PHP Medicare Advantage	$0.43
Rate for Payer: Priority Health Cigna Priority Health	$13.00
Rate for Payer: Priority Health Medicare	$0.43
Rate for Payer: UHC All Payor (Choice/PPO)	$0.43
Rate for Payer: UHC Dual Complete DSNP	$0.43
Rate for Payer: UHC Exchange	$0.43
Rate for Payer: UHC Medicare Advantage	$0.43

PR CERCLAGE CERVIX PREGNANCY VAGINAL

Professional

Both

$734.00

Service Code	HCPCS 59320
Min. Negotiated Rate	$148.54
Max. Negotiated Rate	$477.10
Rate for Payer: Aetna Commercial	$199.04
Rate for Payer: Aetna Medicare	$154.48
Rate for Payer: BCBS Complete	$293.60
Rate for Payer: BCBS MAPPO	$148.54
Rate for Payer: BCN Medicare Advantage	$148.54
Rate for Payer: Cash Price	$587.20
Rate for Payer: Cash Price	$587.20
Rate for Payer: Cofinity Commercial	$213.90
Rate for Payer: Cofinity Commercial	$199.04
Rate for Payer: Health Alliance Plan Medicare Advantage	$148.54
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$155.97
Rate for Payer: Nomi Health Commercial	$178.25
Rate for Payer: PACE SWMI	$148.54
Rate for Payer: PHP Medicare Advantage	$148.54
Rate for Payer: Priority Health Cigna Priority Health	$477.10
Rate for Payer: Priority Health Medicare	$150.03
Rate for Payer: UHC All Payor (Choice/PPO)	$148.54
Rate for Payer: UHC Dual Complete DSNP	$148.54
Rate for Payer: UHC Exchange	$148.54
Rate for Payer: UHC Medicare Advantage	$148.54

PR CERCLAGE UTERINE CERVIX NONOBSTETRICAL

Professional

Both

$827.00

Service Code	HCPCS 57700
Min. Negotiated Rate	$330.80
Max. Negotiated Rate	$537.55
Rate for Payer: Aetna Commercial	$448.65
Rate for Payer: Aetna Medicare	$348.20
Rate for Payer: BCBS Complete	$330.80
Rate for Payer: BCBS MAPPO	$334.81
Rate for Payer: BCN Medicare Advantage	$334.81
Rate for Payer: Cash Price	$661.60
Rate for Payer: Cash Price	$661.60
Rate for Payer: Cofinity Commercial	$482.13
Rate for Payer: Cofinity Commercial	$448.65
Rate for Payer: Health Alliance Plan Medicare Advantage	$334.81
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$351.55
Rate for Payer: Nomi Health Commercial	$401.77
Rate for Payer: PACE SWMI	$334.81
Rate for Payer: PHP Medicare Advantage	$334.81
Rate for Payer: Priority Health Cigna Priority Health	$537.55
Rate for Payer: Priority Health Medicare	$338.16
Rate for Payer: UHC All Payor (Choice/PPO)	$334.81
Rate for Payer: UHC Dual Complete DSNP	$334.81
Rate for Payer: UHC Exchange	$334.81
Rate for Payer: UHC Medicare Advantage	$334.81

PR CERTOLIZUMAB PEGOL INJ 1MG

Professional

Both

$10.00

Service Code	HCPCS J0717
Min. Negotiated Rate	$3.91
Max. Negotiated Rate	$6.50
Rate for Payer: Aetna Commercial	$5.24
Rate for Payer: Aetna Medicare	$4.07
Rate for Payer: BCBS Complete	$4.00
Rate for Payer: BCBS MAPPO	$3.91
Rate for Payer: BCN Medicare Advantage	$3.91
Rate for Payer: Cash Price	$8.00
Rate for Payer: Cash Price	$8.00
Rate for Payer: Cofinity Commercial	$5.63
Rate for Payer: Cofinity Commercial	$5.24
Rate for Payer: Health Alliance Plan Medicare Advantage	$3.91
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$4.11
Rate for Payer: Nomi Health Commercial	$4.69
Rate for Payer: PACE SWMI	$3.91
Rate for Payer: PHP Medicare Advantage	$3.91
Rate for Payer: Priority Health Cigna Priority Health	$6.50
Rate for Payer: Priority Health Medicare	$3.95
Rate for Payer: UHC All Payor (Choice/PPO)	$3.91
Rate for Payer: UHC Dual Complete DSNP	$3.91
Rate for Payer: UHC Exchange	$3.91
Rate for Payer: UHC Medicare Advantage	$3.91

PR CERV FLEX N/ADJ FOAM PRE OTS

Professional

Both

$27.00

Service Code	HCPCS L0120
Min. Negotiated Rate	$10.80
Max. Negotiated Rate	$45.89
Rate for Payer: Aetna Commercial	$42.71
Rate for Payer: Aetna Medicare	$33.14
Rate for Payer: BCBS Complete	$10.80
Rate for Payer: BCBS MAPPO	$31.87
Rate for Payer: BCN Medicare Advantage	$31.87
Rate for Payer: Cash Price	$21.60
Rate for Payer: Cash Price	$21.60
Rate for Payer: Cofinity Commercial	$45.89
Rate for Payer: Cofinity Commercial	$42.71
Rate for Payer: Health Alliance Plan Medicare Advantage	$31.87
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$33.46
Rate for Payer: Nomi Health Commercial	$38.24
Rate for Payer: PACE SWMI	$31.87
Rate for Payer: PHP Medicare Advantage	$31.87
Rate for Payer: Priority Health Cigna Priority Health	$17.55
Rate for Payer: Priority Health Medicare	$32.19
Rate for Payer: UHC All Payor (Choice/PPO)	$31.87
Rate for Payer: UHC Dual Complete DSNP	$31.87
Rate for Payer: UHC Exchange	$31.87
Rate for Payer: UHC Medicare Advantage	$31.87

PR CERVICAL CAP CONTRACEPTIVE

Professional

Both

$102.00

Service Code	HCPCS A4261
Min. Negotiated Rate	$40.80
Max. Negotiated Rate	$66.30
Rate for Payer: Aetna Medicare	$51.00
Rate for Payer: BCBS Complete	$40.80
Rate for Payer: Cash Price	$81.60
Rate for Payer: Priority Health Cigna Priority Health	$66.30

PR CERVICAL LYMPHADEC MODIFIED RADICAL NECK DSJ

Professional

Both

$3,995.00

Service Code	HCPCS 38724
Min. Negotiated Rate	$1,389.43
Max. Negotiated Rate	$2,596.75
Rate for Payer: Aetna Commercial	$1,861.84
Rate for Payer: Aetna Medicare	$1,445.01
Rate for Payer: BCBS Complete	$1,598.00
Rate for Payer: BCBS MAPPO	$1,389.43
Rate for Payer: BCN Medicare Advantage	$1,389.43
Rate for Payer: Cash Price	$3,196.00
Rate for Payer: Cash Price	$3,196.00
Rate for Payer: Cofinity Commercial	$2,000.78
Rate for Payer: Cofinity Commercial	$1,861.84
Rate for Payer: Health Alliance Plan Medicare Advantage	$1,389.43
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$1,458.90
Rate for Payer: Nomi Health Commercial	$1,667.32
Rate for Payer: PACE SWMI	$1,389.43
Rate for Payer: PHP Medicare Advantage	$1,389.43
Rate for Payer: Priority Health Cigna Priority Health	$2,596.75
Rate for Payer: Priority Health Medicare	$1,403.32
Rate for Payer: UHC All Payor (Choice/PPO)	$1,389.43
Rate for Payer: UHC Dual Complete DSNP	$1,389.43
Rate for Payer: UHC Exchange	$1,389.43
Rate for Payer: UHC Medicare Advantage	$1,389.43

PR CERVICAL LYMPHADENECTOMY

Professional

Both

$2,444.00

Service Code	HCPCS 38720
Min. Negotiated Rate	$977.60
Max. Negotiated Rate	$1,858.65
Rate for Payer: Aetna Commercial	$1,729.58
Rate for Payer: Aetna Medicare	$1,342.36
Rate for Payer: BCBS Complete	$977.60
Rate for Payer: BCBS MAPPO	$1,290.73
Rate for Payer: BCN Medicare Advantage	$1,290.73
Rate for Payer: Cash Price	$1,955.20
Rate for Payer: Cash Price	$1,955.20
Rate for Payer: Cofinity Commercial	$1,858.65
Rate for Payer: Cofinity Commercial	$1,729.58
Rate for Payer: Health Alliance Plan Medicare Advantage	$1,290.73
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$1,355.27
Rate for Payer: Nomi Health Commercial	$1,548.88
Rate for Payer: PACE SWMI	$1,290.73
Rate for Payer: PHP Medicare Advantage	$1,290.73
Rate for Payer: Priority Health Cigna Priority Health	$1,588.60
Rate for Payer: Priority Health Medicare	$1,303.64
Rate for Payer: UHC All Payor (Choice/PPO)	$1,290.73
Rate for Payer: UHC Dual Complete DSNP	$1,290.73
Rate for Payer: UHC Exchange	$1,290.73
Rate for Payer: UHC Medicare Advantage	$1,290.73

PR CESAREAN DELIVERY ATTEMPTED VBAC

Professional

Both

$2,499.00

Service Code	HCPCS 59620
Min. Negotiated Rate	$920.36
Max. Negotiated Rate	$1,624.35
Rate for Payer: Aetna Commercial	$1,233.28
Rate for Payer: Aetna Medicare	$957.17
Rate for Payer: BCBS Complete	$999.60
Rate for Payer: BCBS MAPPO	$920.36
Rate for Payer: BCN Medicare Advantage	$920.36
Rate for Payer: Cash Price	$1,999.20
Rate for Payer: Cash Price	$1,999.20
Rate for Payer: Cofinity Commercial	$1,325.32
Rate for Payer: Cofinity Commercial	$1,233.28
Rate for Payer: Health Alliance Plan Medicare Advantage	$920.36
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$966.38
Rate for Payer: Nomi Health Commercial	$1,104.43
Rate for Payer: PACE SWMI	$920.36
Rate for Payer: PHP Medicare Advantage	$920.36
Rate for Payer: Priority Health Cigna Priority Health	$1,624.35
Rate for Payer: Priority Health Medicare	$929.56
Rate for Payer: UHC All Payor (Choice/PPO)	$920.36
Rate for Payer: UHC Dual Complete DSNP	$920.36
Rate for Payer: UHC Exchange	$920.36
Rate for Payer: UHC Medicare Advantage	$920.36

PR CESAREAN DELIVERY ONLY

Professional

Both

$2,321.00

Service Code	HCPCS 59514
Min. Negotiated Rate	$888.51
Max. Negotiated Rate	$1,508.65
Rate for Payer: Aetna Commercial	$1,190.60
Rate for Payer: Aetna Medicare	$924.05
Rate for Payer: BCBS Complete	$928.40
Rate for Payer: BCBS MAPPO	$888.51
Rate for Payer: BCN Medicare Advantage	$888.51
Rate for Payer: Cash Price	$1,856.80
Rate for Payer: Cash Price	$1,856.80
Rate for Payer: Cofinity Commercial	$1,279.45
Rate for Payer: Cofinity Commercial	$1,190.60
Rate for Payer: Health Alliance Plan Medicare Advantage	$888.51
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$932.94
Rate for Payer: Nomi Health Commercial	$1,066.21
Rate for Payer: PACE SWMI	$888.51
Rate for Payer: PHP Medicare Advantage	$888.51
Rate for Payer: Priority Health Cigna Priority Health	$1,508.65
Rate for Payer: Priority Health Medicare	$897.40
Rate for Payer: UHC All Payor (Choice/PPO)	$888.51
Rate for Payer: UHC Dual Complete DSNP	$888.51
Rate for Payer: UHC Exchange	$888.51
Rate for Payer: UHC Medicare Advantage	$888.51

PR CESAREAN DELIVERY ONLY W/POSTPARTUM CARE

Professional

Both

$2,593.00

Service Code	HCPCS 59515
Min. Negotiated Rate	$1,037.20
Max. Negotiated Rate	$1,888.01
Rate for Payer: Aetna Commercial	$1,756.90
Rate for Payer: Aetna Medicare	$1,363.56
Rate for Payer: BCBS Complete	$1,037.20
Rate for Payer: BCBS MAPPO	$1,311.12
Rate for Payer: BCN Medicare Advantage	$1,311.12
Rate for Payer: Cash Price	$2,074.40
Rate for Payer: Cash Price	$2,074.40
Rate for Payer: Cofinity Commercial	$1,888.01
Rate for Payer: Cofinity Commercial	$1,756.90
Rate for Payer: Health Alliance Plan Medicare Advantage	$1,311.12
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$1,376.68
Rate for Payer: Nomi Health Commercial	$1,573.34
Rate for Payer: PACE SWMI	$1,311.12
Rate for Payer: PHP Medicare Advantage	$1,311.12
Rate for Payer: Priority Health Cigna Priority Health	$1,685.45
Rate for Payer: Priority Health Medicare	$1,324.23
Rate for Payer: UHC All Payor (Choice/PPO)	$1,311.12
Rate for Payer: UHC Dual Complete DSNP	$1,311.12
Rate for Payer: UHC Exchange	$1,311.12
Rate for Payer: UHC Medicare Advantage	$1,311.12

Know your out-of-pocket cost for care.

All Charges