Bronson Lakeview Hospital

All Charges

Charge

Type

Setting

Price

PR FINE NEEDLE ASP;W/IMAGING GUIDANCE

Professional

Both

$277.00

Service Code	HCPCS 10022
Min. Negotiated Rate	$110.80
Max. Negotiated Rate	$207.75
Rate for Payer: Aetna Medicare	$138.50
Rate for Payer: BCBS Complete	$110.80
Rate for Payer: Cash Price	$221.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$207.75

PR FINGER SPLINT, STATIC

Professional

Both

$5.00

Service Code	HCPCS Q4049
Min. Negotiated Rate	$1.77
Max. Negotiated Rate	$3.75
Rate for Payer: Aetna Commercial	$1.77
Rate for Payer: Aetna Medicare	$2.50
Rate for Payer: BCN Commercial	$2.57
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 FISSURECTOMY INCL SPHINCTEROTOMY WHEN PERFORMED

Professional

Both

$991.00

Service Code	HCPCS 46200
Min. Negotiated Rate	$221.73
Max. Negotiated Rate	$743.25
Rate for Payer: Aetna Commercial	$443.17
Rate for Payer: Aetna Medicare	$495.50
Rate for Payer: BCBS Complete	$232.82
Rate for Payer: BCN Commercial	$515.90
Rate for Payer: Cash Price	$792.80
Rate for Payer: Cash Price	$792.80
Rate for Payer: Mclaren Medicaid	$221.73
Rate for Payer: Meridian Medicaid	$232.82
Rate for Payer: Opus (Opus Packaging Group) HMA	$743.25
Rate for Payer: Priority Health Choice Medicaid	$221.73
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$628.60
Rate for Payer: Priority Health Narrow/Tiered Network	$628.60
Rate for Payer: UHC Medicaid	$221.73
Rate for Payer: UHCCP Medicaid	$221.73

PR FIT CONTACT LENS TX OCULAR SURFACE DISEASE

Professional

Both

$69.00

Service Code	HCPCS 92071
Min. Negotiated Rate	$16.61
Max. Negotiated Rate	$51.75
Rate for Payer: Aetna Commercial	$35.00
Rate for Payer: Aetna Medicare	$34.50
Rate for Payer: BCBS Complete	$17.44
Rate for Payer: BCN Commercial	$47.31
Rate for Payer: Cash Price	$55.20
Rate for Payer: Cash Price	$55.20
Rate for Payer: Mclaren Medicaid	$16.61
Rate for Payer: Meridian Medicaid	$17.44
Rate for Payer: Opus (Opus Packaging Group) HMA	$51.75
Rate for Payer: Priority Health Choice Medicaid	$16.61
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$40.48
Rate for Payer: Priority Health Narrow/Tiered Network	$40.48
Rate for Payer: UHC Medicaid	$16.61
Rate for Payer: UHCCP Medicaid	$16.61

PR FIT&INSJ PESSARY/OTH INTRAVAGINAL SUPPORT DEVI

Professional

Both

$132.00

Service Code	HCPCS 57160
Min. Negotiated Rate	$25.77
Max. Negotiated Rate	$99.00
Rate for Payer: Aetna Commercial	$55.97
Rate for Payer: Aetna Medicare	$66.00
Rate for Payer: BCBS Complete	$27.06
Rate for Payer: BCN Commercial	$68.72
Rate for Payer: Cash Price	$105.60
Rate for Payer: Cash Price	$105.60
Rate for Payer: Mclaren Medicaid	$25.77
Rate for Payer: Meridian Medicaid	$27.06
Rate for Payer: Opus (Opus Packaging Group) HMA	$99.00
Rate for Payer: Priority Health Choice Medicaid	$25.77
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$69.60
Rate for Payer: Priority Health Narrow/Tiered Network	$69.60
Rate for Payer: UHC Medicaid	$25.77
Rate for Payer: UHCCP Medicaid	$25.77

PR FITTING CONTACT LENS FOR MGMT OF KERATOCONUS 1ST

Professional

Both

$228.00

Service Code	HCPCS 92072
Min. Negotiated Rate	$48.78
Max. Negotiated Rate	$171.00
Rate for Payer: Aetna Commercial	$104.39
Rate for Payer: Aetna Medicare	$114.00
Rate for Payer: BCBS Complete	$51.22
Rate for Payer: BCN Commercial	$136.44
Rate for Payer: Cash Price	$182.40
Rate for Payer: Cash Price	$182.40
Rate for Payer: Mclaren Medicaid	$48.78
Rate for Payer: Meridian Medicaid	$51.22
Rate for Payer: Opus (Opus Packaging Group) HMA	$171.00
Rate for Payer: Priority Health Choice Medicaid	$48.78
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$116.75
Rate for Payer: Priority Health Narrow/Tiered Network	$116.75
Rate for Payer: UHC Medicaid	$48.78
Rate for Payer: UHCCP Medicaid	$48.78

PR FIXATION CONTRALATERAL TESTIS SEPARATE PROCEDURE

Professional

Both

$591.00

Service Code	HCPCS 54620
Min. Negotiated Rate	$173.81
Max. Negotiated Rate	$487.68
Rate for Payer: Aetna Commercial	$383.67
Rate for Payer: Aetna Medicare	$295.50
Rate for Payer: BCBS Complete	$182.50
Rate for Payer: BCN Commercial	$447.69
Rate for Payer: Cash Price	$472.80
Rate for Payer: Cash Price	$472.80
Rate for Payer: Mclaren Medicaid	$173.81
Rate for Payer: Meridian Medicaid	$182.50
Rate for Payer: Opus (Opus Packaging Group) HMA	$443.25
Rate for Payer: Priority Health Choice Medicaid	$173.81
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$487.68
Rate for Payer: Priority Health Narrow/Tiered Network	$487.68
Rate for Payer: UHC Medicaid	$173.81
Rate for Payer: UHCCP Medicaid	$173.81

PR FLAP ISLAND PEDICLE ANATOMIC NAMED AXIAL ARTERY

Professional

Both

$1,785.00

Service Code	HCPCS 15740
Min. Negotiated Rate	$479.04
Max. Negotiated Rate	$1,338.75
Rate for Payer: Aetna Commercial	$895.75
Rate for Payer: Aetna Medicare	$892.50
Rate for Payer: BCBS Complete	$502.99
Rate for Payer: BCN Commercial	$1,270.85
Rate for Payer: Cash Price	$1,428.00
Rate for Payer: Cash Price	$1,428.00
Rate for Payer: Mclaren Medicaid	$479.04
Rate for Payer: Meridian Medicaid	$502.99
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,338.75
Rate for Payer: Priority Health Choice Medicaid	$479.04
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$1,163.15
Rate for Payer: Priority Health Narrow/Tiered Network	$1,163.15
Rate for Payer: UHC Medicaid	$479.04
Rate for Payer: UHCCP Medicaid	$479.04

PR FLUORESCEIN ANGIOSCOPY INTERPRETATION & REPORT

Professional

Both

$122.00

Service Code	HCPCS 92230
Min. Negotiated Rate	$17.04
Max. Negotiated Rate	$91.50
Rate for Payer: Aetna Commercial	$36.07
Rate for Payer: Aetna Medicare	$61.00
Rate for Payer: BCBS Complete	$17.89
Rate for Payer: BCN Commercial	$46.81
Rate for Payer: Cash Price	$97.60
Rate for Payer: Cash Price	$97.60
Rate for Payer: Mclaren Medicaid	$17.04
Rate for Payer: Meridian Medicaid	$17.89
Rate for Payer: Opus (Opus Packaging Group) HMA	$91.50
Rate for Payer: Priority Health Choice Medicaid	$17.04
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$40.06
Rate for Payer: Priority Health Narrow/Tiered Network	$40.06
Rate for Payer: UHC Medicaid	$17.04
Rate for Payer: UHCCP Medicaid	$17.04

PR FLUPHENAZINE DECANOATE 25 MG

Professional

Both

$25.00

Service Code	HCPCS J2680
Min. Negotiated Rate	$4.04
Max. Negotiated Rate	$18.75
Rate for Payer: Aetna Commercial	$9.42
Rate for Payer: Aetna Medicare	$12.50
Rate for Payer: BCBS Trust/PPO	$4.04
Rate for Payer: BCN Commercial	$5.66
Rate for Payer: Cash Price	$20.00
Rate for Payer: Cash Price	$20.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$18.75

PR FLUVIRIN VACC, 3 YRS & >, IM

Professional

Both

$21.00

Service Code	HCPCS Q2037
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$18.62
Rate for Payer: Aetna Commercial	$18.62
Rate for Payer: Aetna Medicare	$10.50
Rate for Payer: BCBS Complete	$8.40
Rate for Payer: BCBS Trust/PPO	$0.01
Rate for Payer: BCN Commercial	$0.01
Rate for Payer: Cash Price	$16.80
Rate for Payer: Cash Price	$16.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$15.75

PR FLUZONE VACC, 3 YRS & >, IM

Professional

Both

$27.00

Service Code	HCPCS Q2038
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$20.25
Rate for Payer: Aetna Commercial	$12.68
Rate for Payer: Aetna Medicare	$13.50
Rate for Payer: BCBS Complete	$10.80
Rate for Payer: BCBS Trust/PPO	$0.01
Rate for Payer: BCN Commercial	$0.01
Rate for Payer: Cash Price	$21.60
Rate for Payer: Cash Price	$21.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$20.25

PR FOLLOWUP EVAL OF FOOT PT LOP

Professional

Both

$48.00

Service Code	HCPCS G0246
Min. Negotiated Rate	$19.20
Max. Negotiated Rate	$36.00
Rate for Payer: Aetna Commercial	$20.40
Rate for Payer: Aetna Medicare	$24.00
Rate for Payer: BCBS Complete	$19.20
Rate for Payer: BCN Commercial	$29.38
Rate for Payer: Cash Price	$38.40
Rate for Payer: Cash Price	$38.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$36.00
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$22.37
Rate for Payer: Priority Health Narrow/Tiered Network	$22.37

PR FOLLOW-UP/REASSESSMENT

Professional

Both

$315.00

Service Code	HCPCS S0316
Min. Negotiated Rate	$20.00
Max. Negotiated Rate	$236.25
Rate for Payer: Aetna Commercial	$20.00
Rate for Payer: Aetna Medicare	$157.50
Rate for Payer: BCBS Complete	$126.00
Rate for Payer: Cash Price	$252.00
Rate for Payer: Cash Price	$252.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$236.25

PR FO NONTORSION JOINT CF

Professional

Both

$213.00

Service Code	HCPCS L3935
Min. Negotiated Rate	$85.20
Max. Negotiated Rate	$236.55
Rate for Payer: Aetna Commercial	$121.09
Rate for Payer: Aetna Medicare	$106.50
Rate for Payer: BCBS Complete	$85.20
Rate for Payer: BCN Commercial	$236.55
Rate for Payer: Cash Price	$170.40
Rate for Payer: Cash Price	$170.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$159.75

PR FOOT ARCH SUPP LONGITUD/META

Professional

Both

$42.00

Service Code	HCPCS L3060
Min. Negotiated Rate	$16.80
Max. Negotiated Rate	$86.79
Rate for Payer: Aetna Commercial	$44.42
Rate for Payer: Aetna Medicare	$21.00
Rate for Payer: BCBS Complete	$16.80
Rate for Payer: BCN Commercial	$86.79
Rate for Payer: Cash Price	$33.60
Rate for Payer: Cash Price	$33.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$31.50

PR FOOT PLAS HEEL STABI PRE OTS

Professional

Both

$52.00

Service Code	HCPCS L3170
Min. Negotiated Rate	$20.80
Max. Negotiated Rate	$59.85
Rate for Payer: Aetna Commercial	$30.64
Rate for Payer: Aetna Medicare	$26.00
Rate for Payer: BCBS Complete	$20.80
Rate for Payer: BCN Commercial	$59.85
Rate for Payer: Cash Price	$41.60
Rate for Payer: Cash Price	$41.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$39.00

PR FO PIP DIP JNT/SPRNG PRE OTS

Professional

Both

$64.00

Service Code	HCPCS L3925
Min. Negotiated Rate	$25.60
Max. Negotiated Rate	$70.34
Rate for Payer: Aetna Commercial	$36.01
Rate for Payer: Aetna Medicare	$32.00
Rate for Payer: BCBS Complete	$25.60
Rate for Payer: BCN Commercial	$70.34
Rate for Payer: Cash Price	$51.20
Rate for Payer: Cash Price	$51.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$48.00

PR FOREARM/ARM CUFFS FREE MOTIO

Professional

Both

$657.00

Service Code	HCPCS L3720
Min. Negotiated Rate	$262.80
Max. Negotiated Rate	$731.68
Rate for Payer: Aetna Commercial	$374.53
Rate for Payer: Aetna Medicare	$328.50
Rate for Payer: BCBS Complete	$262.80
Rate for Payer: BCN Commercial	$731.68
Rate for Payer: Cash Price	$525.60
Rate for Payer: Cash Price	$525.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$492.75

PR FOREHEAD FLAP W/PRESERVATION VASCULAR PEDICLE

Professional

Both

$2,327.00

Service Code	HCPCS 15731
Min. Negotiated Rate	$559.55
Max. Negotiated Rate	$1,745.25
Rate for Payer: Aetna Commercial	$1,071.45
Rate for Payer: Aetna Medicare	$1,163.50
Rate for Payer: BCBS Complete	$587.53
Rate for Payer: BCN Commercial	$1,498.42
Rate for Payer: Cash Price	$1,861.60
Rate for Payer: Cash Price	$1,861.60
Rate for Payer: Mclaren Medicaid	$559.55
Rate for Payer: Meridian Medicaid	$587.53
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,745.25
Rate for Payer: Priority Health Choice Medicaid	$559.55
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$1,371.45
Rate for Payer: Priority Health Narrow/Tiered Network	$1,371.45
Rate for Payer: UHC Medicaid	$559.55
Rate for Payer: UHCCP Medicaid	$559.55

PR FORESKN MANJ W/LSS PREPUTIAL ADS&STRETCHING

Professional

Both

$158.00

Service Code	HCPCS 54450
Min. Negotiated Rate	$32.16
Max. Negotiated Rate	$118.50
Rate for Payer: Aetna Commercial	$73.96
Rate for Payer: Aetna Medicare	$79.00
Rate for Payer: BCBS Complete	$33.77
Rate for Payer: BCN Commercial	$85.15
Rate for Payer: Cash Price	$126.40
Rate for Payer: Cash Price	$126.40
Rate for Payer: Mclaren Medicaid	$32.16
Rate for Payer: Meridian Medicaid	$33.77
Rate for Payer: Opus (Opus Packaging Group) HMA	$118.50
Rate for Payer: Priority Health Choice Medicaid	$32.16
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$92.76
Rate for Payer: Priority Health Narrow/Tiered Network	$92.76
Rate for Payer: UHC Medicaid	$32.16
Rate for Payer: UHCCP Medicaid	$32.16

PR FO W/O JOINTS CF

Professional

Both

$206.00

Service Code	HCPCS L3933
Min. Negotiated Rate	$82.40
Max. Negotiated Rate	$228.48
Rate for Payer: Aetna Commercial	$116.96
Rate for Payer: Aetna Medicare	$103.00
Rate for Payer: BCBS Complete	$82.40
Rate for Payer: BCN Commercial	$228.48
Rate for Payer: Cash Price	$164.80
Rate for Payer: Cash Price	$164.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$154.50

PR FRAC FL FACE

Professional

Both

$420.00

Hospital Revenue Code	990
Min. Negotiated Rate	$168.00
Max. Negotiated Rate	$315.00
Rate for Payer: Aetna Medicare	$210.00
Rate for Payer: BCBS Complete	$168.00
Rate for Payer: Cash Price	$336.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$315.00

PR FRAC NECK

Professional

Both

$158.00

Hospital Revenue Code	990
Min. Negotiated Rate	$63.20
Max. Negotiated Rate	$118.50
Rate for Payer: Aetna Medicare	$79.00
Rate for Payer: BCBS Complete	$63.20
Rate for Payer: Cash Price	$126.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$118.50

PR FRAC SCARS PER INCH

Professional

Both

$53.00

Hospital Revenue Code	990
Min. Negotiated Rate	$21.20
Max. Negotiated Rate	$39.75
Rate for Payer: Aetna Medicare	$26.50
Rate for Payer: BCBS Complete	$21.20
Rate for Payer: Cash Price	$42.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$39.75

Know your out-of-pocket cost for care.

All Charges