Bronson Lakeview Hospital

All Charges

Charge

Type

Setting

Price

PR ESRD RELATED SVC MONTHLY 20&/>YR OLD 1 VISIT

Professional

Both

$330.00

Service Code	HCPCS 90962
Min. Negotiated Rate	$137.17
Max. Negotiated Rate	$302.77
Rate for Payer: Aetna Commercial	$222.67
Rate for Payer: Aetna Medicare	$165.00
Rate for Payer: BCBS Complete	$144.03
Rate for Payer: BCN Commercial	$302.77
Rate for Payer: Cash Price	$264.00
Rate for Payer: Cash Price	$264.00
Rate for Payer: Mclaren Medicaid	$137.17
Rate for Payer: Meridian Medicaid	$144.03
Rate for Payer: Opus (Opus Packaging Group) HMA	$247.50
Rate for Payer: Priority Health Choice Medicaid	$137.17
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$279.23
Rate for Payer: Priority Health Narrow/Tiered Network	$279.23
Rate for Payer: UHC Medicaid	$137.17
Rate for Payer: UHCCP Medicaid	$137.17

PR ESRD RELATED SVC MONTHLY 20/>YR OLD 2/3 VISITS

Professional

Both

$426.00

Service Code	HCPCS 90961
Min. Negotiated Rate	$198.09
Max. Negotiated Rate	$438.23
Rate for Payer: Aetna Commercial	$326.25
Rate for Payer: Aetna Medicare	$213.00
Rate for Payer: BCBS Complete	$207.99
Rate for Payer: BCN Commercial	$438.23
Rate for Payer: Cash Price	$340.80
Rate for Payer: Cash Price	$340.80
Rate for Payer: Mclaren Medicaid	$198.09
Rate for Payer: Meridian Medicaid	$207.99
Rate for Payer: Opus (Opus Packaging Group) HMA	$319.50
Rate for Payer: Priority Health Choice Medicaid	$198.09
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$404.14
Rate for Payer: Priority Health Narrow/Tiered Network	$404.14
Rate for Payer: UHC Medicaid	$198.09
Rate for Payer: UHCCP Medicaid	$198.09

PR ESRD RELATED SVC MONTHLY 20&/> YR OLD 4/> VISITS

Professional

Both

$507.00

Service Code	HCPCS 90960
Min. Negotiated Rate	$237.71
Max. Negotiated Rate	$527.86
Rate for Payer: Aetna Commercial	$394.57
Rate for Payer: Aetna Medicare	$253.50
Rate for Payer: BCBS Complete	$249.60
Rate for Payer: BCN Commercial	$527.86
Rate for Payer: Cash Price	$405.60
Rate for Payer: Cash Price	$405.60
Rate for Payer: Mclaren Medicaid	$237.71
Rate for Payer: Meridian Medicaid	$249.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$380.25
Rate for Payer: Priority Health Choice Medicaid	$237.71
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$486.79
Rate for Payer: Priority Health Narrow/Tiered Network	$486.79
Rate for Payer: UHC Medicaid	$237.71
Rate for Payer: UHCCP Medicaid	$237.71

PR ESRD SVC HOME DIALYSIS FULL MONTH 20 YR OLD

Professional

Both

$438.00

Service Code	HCPCS 90966
Min. Negotiated Rate	$197.88
Max. Negotiated Rate	$438.23
Rate for Payer: Aetna Commercial	$325.90
Rate for Payer: Aetna Medicare	$219.00
Rate for Payer: BCBS Complete	$207.77
Rate for Payer: BCN Commercial	$438.23
Rate for Payer: Cash Price	$350.40
Rate for Payer: Cash Price	$350.40
Rate for Payer: Mclaren Medicaid	$197.88
Rate for Payer: Meridian Medicaid	$207.77
Rate for Payer: Opus (Opus Packaging Group) HMA	$328.50
Rate for Payer: Priority Health Choice Medicaid	$197.88
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$404.14
Rate for Payer: Priority Health Narrow/Tiered Network	$404.14
Rate for Payer: UHC Medicaid	$197.88
Rate for Payer: UHCCP Medicaid	$197.88

PR ESW BY PHYS W/ANES INVG LAT HUMERL EPICONDYLE

Professional

Both

$2,735.00

Service Code	HCPCS 0102T
Min. Negotiated Rate	$391.44
Max. Negotiated Rate	$3,033.71
Rate for Payer: Aetna Commercial	$391.44
Rate for Payer: Aetna Medicare	$1,367.50
Rate for Payer: BCBS Complete	$1,094.00
Rate for Payer: BCN Commercial	$3,033.71
Rate for Payer: Cash Price	$2,188.00
Rate for Payer: Cash Price	$2,188.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$2,051.25

PR ETHMOIDECTOMY INTRANASAL ANTERIOR

Professional

Both

$2,627.00

Service Code	HCPCS 31200
Min. Negotiated Rate	$372.54
Max. Negotiated Rate	$1,970.25
Rate for Payer: Aetna Commercial	$785.39
Rate for Payer: Aetna Medicare	$1,313.50
Rate for Payer: BCBS Complete	$391.17
Rate for Payer: BCN Commercial	$932.22
Rate for Payer: Cash Price	$2,101.60
Rate for Payer: Cash Price	$2,101.60
Rate for Payer: Mclaren Medicaid	$372.54
Rate for Payer: Meridian Medicaid	$391.17
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,970.25
Rate for Payer: Priority Health Choice Medicaid	$372.54
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$877.88
Rate for Payer: Priority Health Narrow/Tiered Network	$877.88
Rate for Payer: UHC Medicaid	$372.54
Rate for Payer: UHCCP Medicaid	$372.54

PR ETHMOIDECTOMY INTRANASAL TOTAL

Professional

Both

$1,580.00

Service Code	HCPCS 31201
Min. Negotiated Rate	$452.41
Max. Negotiated Rate	$1,185.00
Rate for Payer: Aetna Commercial	$1,010.10
Rate for Payer: Aetna Medicare	$790.00
Rate for Payer: BCBS Complete	$475.03
Rate for Payer: BCN Commercial	$1,164.78
Rate for Payer: Cash Price	$1,264.00
Rate for Payer: Cash Price	$1,264.00
Rate for Payer: Mclaren Medicaid	$452.41
Rate for Payer: Meridian Medicaid	$475.03
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,185.00
Rate for Payer: Priority Health Choice Medicaid	$452.41
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$1,096.87
Rate for Payer: Priority Health Narrow/Tiered Network	$1,096.87
Rate for Payer: UHC Medicaid	$452.41
Rate for Payer: UHCCP Medicaid	$452.41

PR ETONOGESTREL IMPLANT SYSTEM

Professional

Both

$1,404.00

Service Code	HCPCS J7307
Min. Negotiated Rate	$702.00
Max. Negotiated Rate	$1,351.89
Rate for Payer: Aetna Commercial	$1,092.48
Rate for Payer: Aetna Medicare	$702.00
Rate for Payer: BCBS Complete	$1,351.89
Rate for Payer: BCBS Trust/PPO	$1,295.81
Rate for Payer: BCN Commercial	$1,235.28
Rate for Payer: Cash Price	$1,123.20
Rate for Payer: Cash Price	$1,123.20
Rate for Payer: Mclaren Medicaid	$1,287.51
Rate for Payer: Meridian Medicaid	$1,351.89
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,053.00
Rate for Payer: Priority Health Choice Medicaid	$1,287.51
Rate for Payer: UHC Medicaid	$1,287.51
Rate for Payer: UHCCP Medicaid	$1,287.51

PR EUFLEXXA INJ PER DOSE

Professional

Both

$304.00

Service Code	HCPCS J7323
Min. Negotiated Rate	$107.45
Max. Negotiated Rate	$228.00
Rate for Payer: Aetna Commercial	$131.12
Rate for Payer: Aetna Medicare	$152.00
Rate for Payer: BCBS Trust/PPO	$107.45
Rate for Payer: BCN Commercial	$137.68
Rate for Payer: Cash Price	$243.20
Rate for Payer: Cash Price	$243.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$228.00

PR EVACUATION SUBUNGUAL HEMATOMA

Professional

Both

$84.00

Service Code	HCPCS 11740
Min. Negotiated Rate	$20.02
Max. Negotiated Rate	$63.00
Rate for Payer: Aetna Commercial	$31.68
Rate for Payer: Aetna Medicare	$42.00
Rate for Payer: BCBS Complete	$21.02
Rate for Payer: BCN Commercial	$38.88
Rate for Payer: Cash Price	$67.20
Rate for Payer: Cash Price	$67.20
Rate for Payer: Mclaren Medicaid	$20.02
Rate for Payer: Meridian Medicaid	$21.02
Rate for Payer: Opus (Opus Packaging Group) HMA	$63.00
Rate for Payer: Priority Health Choice Medicaid	$20.02
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$45.12
Rate for Payer: Priority Health Narrow/Tiered Network	$45.12
Rate for Payer: UHC Medicaid	$20.02
Rate for Payer: UHCCP Medicaid	$20.02

PR EVAL AUD FUNCJ CAND/PO SURG IMPLT DEV 1ST HR

Professional

Both

$190.00

Service Code	HCPCS 92626
Min. Negotiated Rate	$38.13
Max. Negotiated Rate	$142.50
Rate for Payer: Aetna Commercial	$82.97
Rate for Payer: Aetna Medicare	$95.00
Rate for Payer: BCBS Complete	$40.04
Rate for Payer: BCN Commercial	$110.55
Rate for Payer: Cash Price	$152.00
Rate for Payer: Cash Price	$152.00
Rate for Payer: Mclaren Medicaid	$38.13
Rate for Payer: Meridian Medicaid	$40.04
Rate for Payer: Opus (Opus Packaging Group) HMA	$142.50
Rate for Payer: Priority Health Choice Medicaid	$38.13
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$101.95
Rate for Payer: Priority Health Narrow/Tiered Network	$101.95
Rate for Payer: UHC Medicaid	$38.13
Rate for Payer: UHCCP Medicaid	$38.13

PR EVAL AUD FUNCJ CAND/PO SURG IMPLT DEV EA ADDL 15

Professional

Both

$45.00

Service Code	HCPCS 92627
Min. Negotiated Rate	$8.95
Max. Negotiated Rate	$33.75
Rate for Payer: Aetna Commercial	$19.69
Rate for Payer: Aetna Medicare	$22.50
Rate for Payer: BCBS Complete	$9.40
Rate for Payer: BCN Commercial	$25.90
Rate for Payer: Cash Price	$36.00
Rate for Payer: Cash Price	$36.00
Rate for Payer: Mclaren Medicaid	$8.95
Rate for Payer: Meridian Medicaid	$9.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$33.75
Rate for Payer: Priority Health Choice Medicaid	$8.95
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$23.88
Rate for Payer: Priority Health Narrow/Tiered Network	$23.88
Rate for Payer: UHC Medicaid	$8.95
Rate for Payer: UHCCP Medicaid	$8.95

PR EVAL CENTRAL AUDITORY FUNCJ W/REPRT 1ST 60 MIN

Professional

Both

$173.00

Service Code	HCPCS 92620
Min. Negotiated Rate	$69.20
Max. Negotiated Rate	$129.75
Rate for Payer: Aetna Commercial	$88.66
Rate for Payer: Aetna Medicare	$86.50
Rate for Payer: BCBS Complete	$69.20
Rate for Payer: BCN Commercial	$118.03
Rate for Payer: Cash Price	$138.40
Rate for Payer: Cash Price	$138.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$129.75
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$108.84
Rate for Payer: Priority Health Narrow/Tiered Network	$108.84

PR EVAL CENTRAL AUDITORY FUNCJ W/REPRT EA 15 MIN

Professional

Both

$41.00

Service Code	HCPCS 92621
Min. Negotiated Rate	$16.40
Max. Negotiated Rate	$30.75
Rate for Payer: Aetna Commercial	$20.83
Rate for Payer: Aetna Medicare	$20.50
Rate for Payer: BCBS Complete	$16.40
Rate for Payer: BCN Commercial	$27.89
Rate for Payer: Cash Price	$32.80
Rate for Payer: Cash Price	$32.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$30.75
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$25.71
Rate for Payer: Priority Health Narrow/Tiered Network	$25.71

PR EVAL OF ORTHOTIC/PROSTH USE, EA 15 MIN

Professional

Both

$77.00

Service Code	HCPCS 97762
Min. Negotiated Rate	$30.80
Max. Negotiated Rate	$57.75
Rate for Payer: Aetna Medicare	$38.50
Rate for Payer: BCBS Complete	$30.80
Rate for Payer: Cash Price	$61.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$57.75

PR EVAL SPEECH SOUND PRODUCT LANGUAGE COMPREHENSION

Professional

Both

$368.00

Service Code	HCPCS 92523
Min. Negotiated Rate	$184.00
Max. Negotiated Rate	$344.11
Rate for Payer: Aetna Commercial	$210.67
Rate for Payer: Aetna Medicare	$184.00
Rate for Payer: BCN Commercial	$344.11
Rate for Payer: Cash Price	$294.40
Rate for Payer: Cash Price	$294.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$276.00
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$317.33
Rate for Payer: Priority Health Narrow/Tiered Network	$317.33

PR EVALUATION HEARING AID CANDIDACY 1ST 30 MINUTES

Professional

Both

$147.00

Service Code	HCPCS 92628
Min. Negotiated Rate	$58.80
Max. Negotiated Rate	$110.25
Rate for Payer: Aetna Medicare	$73.50
Rate for Payer: BCBS Complete	$58.80
Rate for Payer: Cash Price	$117.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$110.25

PR EVALUATION HEARING AID CANDIDACY EA ADDL 15 MIN

Professional

Both

$74.00

Service Code	HCPCS 92629
Min. Negotiated Rate	$29.60
Max. Negotiated Rate	$55.50
Rate for Payer: Aetna Medicare	$37.00
Rate for Payer: BCBS Complete	$29.60
Rate for Payer: Cash Price	$59.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$55.50

PR EVALUATION OF SPEECH FLUENCY (STUTTER CLUTTER)

Professional

Both

$217.00

Service Code	HCPCS 92521
Min. Negotiated Rate	$108.50
Max. Negotiated Rate	$201.18
Rate for Payer: Aetna Commercial	$122.55
Rate for Payer: Aetna Medicare	$108.50
Rate for Payer: BCN Commercial	$201.18
Rate for Payer: Cash Price	$173.60
Rate for Payer: Cash Price	$173.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$162.75
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$185.53
Rate for Payer: Priority Health Narrow/Tiered Network	$185.53

PR EVALUATION OF SPEECH SOUND PRODUCTION ARTICULATE

Professional

Both

$176.00

Service Code	HCPCS 92522
Min. Negotiated Rate	$88.00
Max. Negotiated Rate	$167.32
Rate for Payer: Aetna Commercial	$102.73
Rate for Payer: Aetna Medicare	$88.00
Rate for Payer: BCN Commercial	$167.32
Rate for Payer: Cash Price	$140.80
Rate for Payer: Cash Price	$140.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$132.00
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$154.30
Rate for Payer: Priority Health Narrow/Tiered Network	$154.30

PR EVASC INTRACRANIAL PROLNG ADMN RX AGENT ART 1ST

Professional

Both

$1,138.00

Service Code	HCPCS 61650
Min. Negotiated Rate	$333.77
Max. Negotiated Rate	$1,018.55
Rate for Payer: Aetna Commercial	$737.29
Rate for Payer: Aetna Medicare	$569.00
Rate for Payer: BCBS Complete	$350.46
Rate for Payer: BCN Commercial	$876.95
Rate for Payer: Cash Price	$910.40
Rate for Payer: Cash Price	$910.40
Rate for Payer: Mclaren Medicaid	$333.77
Rate for Payer: Meridian Medicaid	$350.46
Rate for Payer: Opus (Opus Packaging Group) HMA	$853.50
Rate for Payer: Priority Health Choice Medicaid	$333.77
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$1,018.55
Rate for Payer: Priority Health Narrow/Tiered Network	$1,018.55
Rate for Payer: UHC Medicaid	$333.77
Rate for Payer: UHCCP Medicaid	$333.77

PR EVASC INTRACRANIAL PROLNG ADMN RX AGENT ART ADDL

Professional

Both

$484.00

Service Code	HCPCS 61651
Min. Negotiated Rate	$142.71
Max. Negotiated Rate	$434.96
Rate for Payer: Aetna Commercial	$316.17
Rate for Payer: Aetna Medicare	$242.00
Rate for Payer: BCBS Complete	$149.85
Rate for Payer: BCN Commercial	$374.49
Rate for Payer: Cash Price	$387.20
Rate for Payer: Cash Price	$387.20
Rate for Payer: Mclaren Medicaid	$142.71
Rate for Payer: Meridian Medicaid	$149.85
Rate for Payer: Opus (Opus Packaging Group) HMA	$363.00
Rate for Payer: Priority Health Choice Medicaid	$142.71
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$434.96
Rate for Payer: Priority Health Narrow/Tiered Network	$434.96
Rate for Payer: UHC Medicaid	$142.71
Rate for Payer: UHCCP Medicaid	$142.71

PR EVASC PLACEMENT ILIAC ARTERY OCCLUSION DEVICE

Professional

Both

$458.00

Service Code	HCPCS 34808
Min. Negotiated Rate	$115.87
Max. Negotiated Rate	$343.50
Rate for Payer: Aetna Commercial	$268.94
Rate for Payer: Aetna Medicare	$229.00
Rate for Payer: BCBS Complete	$121.66
Rate for Payer: BCN Commercial	$294.31
Rate for Payer: Cash Price	$366.40
Rate for Payer: Cash Price	$366.40
Rate for Payer: Mclaren Medicaid	$115.87
Rate for Payer: Meridian Medicaid	$121.66
Rate for Payer: Opus (Opus Packaging Group) HMA	$343.50
Rate for Payer: Priority Health Choice Medicaid	$115.87
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$316.49
Rate for Payer: Priority Health Narrow/Tiered Network	$316.49
Rate for Payer: UHC Medicaid	$115.87
Rate for Payer: UHCCP Medicaid	$115.87

PR EVASC RPR DPLMNT AORTO-AORTIC NDGFT

Professional

Both

$2,666.00

Service Code	HCPCS 34701
Min. Negotiated Rate	$711.63
Max. Negotiated Rate	$1,999.50
Rate for Payer: Aetna Commercial	$1,668.21
Rate for Payer: Aetna Medicare	$1,333.00
Rate for Payer: BCBS Complete	$747.21
Rate for Payer: BCN Commercial	$1,805.19
Rate for Payer: Cash Price	$2,132.80
Rate for Payer: Cash Price	$2,132.80
Rate for Payer: Mclaren Medicaid	$711.63
Rate for Payer: Meridian Medicaid	$747.21
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,999.50
Rate for Payer: Priority Health Choice Medicaid	$711.63
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$1,941.24
Rate for Payer: Priority Health Narrow/Tiered Network	$1,941.24
Rate for Payer: UHC Medicaid	$711.63
Rate for Payer: UHCCP Medicaid	$711.63

PR EVASC RPR DPLMNT AORTO-AORTIC NDGFT RPT

Professional

Both

$4,030.00

Service Code	HCPCS 34702
Min. Negotiated Rate	$1,037.95
Max. Negotiated Rate	$3,022.50
Rate for Payer: Aetna Commercial	$2,491.29
Rate for Payer: Aetna Medicare	$2,015.00
Rate for Payer: BCBS Complete	$1,089.85
Rate for Payer: BCN Commercial	$2,617.39
Rate for Payer: Cash Price	$3,224.00
Rate for Payer: Cash Price	$3,224.00
Rate for Payer: Mclaren Medicaid	$1,037.95
Rate for Payer: Meridian Medicaid	$1,089.85
Rate for Payer: Opus (Opus Packaging Group) HMA	$3,022.50
Rate for Payer: Priority Health Choice Medicaid	$1,037.95
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$2,814.67
Rate for Payer: Priority Health Narrow/Tiered Network	$2,814.67
Rate for Payer: UHC Medicaid	$1,037.95
Rate for Payer: UHCCP Medicaid	$1,037.95

Know your out-of-pocket cost for care.

All Charges