Bronson Lakeview Hospital

All Charges

Charge

Type

Setting

Price

PR HEPB VACCINE ADULT 2/4 DOSE SCHEDULE FOR IM USE

Professional

Both

$336.00

Service Code	HCPCS 90739
Min. Negotiated Rate	$153.25
Max. Negotiated Rate	$252.00
Rate for Payer: Aetna Commercial	$160.28
Rate for Payer: Aetna Medicare	$168.00
Rate for Payer: BCBS Trust/PPO	$155.75
Rate for Payer: BCN Commercial	$153.25
Rate for Payer: Cash Price	$268.80
Rate for Payer: Cash Price	$268.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$252.00

PR HEPB VACCINE ADULT 3 DOSE SCHEDULE FOR IM USE

Professional

Both

$85.00

Service Code	HCPCS 90746
Min. Negotiated Rate	$42.50
Max. Negotiated Rate	$72.21
Rate for Payer: Aetna Commercial	$70.38
Rate for Payer: Aetna Medicare	$42.50
Rate for Payer: BCBS Trust/PPO	$72.21
Rate for Payer: BCN Commercial	$70.96
Rate for Payer: Cash Price	$68.00
Rate for Payer: Cash Price	$68.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$63.75

PR HEPB VACCINE PED/ADOLESC 3 DOSE SCHEDULE IM

Professional

Both

$37.00

Service Code	HCPCS 90744
Min. Negotiated Rate	$18.50
Max. Negotiated Rate	$30.77
Rate for Payer: Aetna Commercial	$30.77
Rate for Payer: Aetna Medicare	$18.50
Rate for Payer: BCBS Trust/PPO	$29.25
Rate for Payer: BCN Commercial	$28.65
Rate for Payer: Cash Price	$29.60
Rate for Payer: Cash Price	$29.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$27.75

PR HFO FLEXION GLOVE PRE OTS

Professional

Both

$102.00

Service Code	HCPCS L3912
Min. Negotiated Rate	$40.80
Max. Negotiated Rate	$112.82
Rate for Payer: Aetna Commercial	$57.75
Rate for Payer: Aetna Medicare	$51.00
Rate for Payer: BCBS Complete	$40.80
Rate for Payer: BCN Commercial	$112.82
Rate for Payer: Cash Price	$81.60
Rate for Payer: Cash Price	$81.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$76.50

PR HFO NONTORSION JNTS PRE CST

Professional

Both

$89.00

Service Code	HCPCS L3929
Min. Negotiated Rate	$35.60
Max. Negotiated Rate	$97.81
Rate for Payer: Aetna Commercial	$50.06
Rate for Payer: Aetna Medicare	$44.50
Rate for Payer: BCBS Complete	$35.60
Rate for Payer: BCN Commercial	$97.81
Rate for Payer: Cash Price	$71.20
Rate for Payer: Cash Price	$71.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$66.75

PR HFO W/JOINT(S) CF

Professional

Both

$309.00

Service Code	HCPCS L3921
Min. Negotiated Rate	$123.60
Max. Negotiated Rate	$343.98
Rate for Payer: Aetna Commercial	$176.08
Rate for Payer: Aetna Medicare	$154.50
Rate for Payer: BCBS Complete	$123.60
Rate for Payer: BCN Commercial	$343.98
Rate for Payer: Cash Price	$247.20
Rate for Payer: Cash Price	$247.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$231.75

PR HFO W/O JOINTS CF

Professional

Both

$261.00

Service Code	HCPCS L3913
Min. Negotiated Rate	$104.40
Max. Negotiated Rate	$290.00
Rate for Payer: Aetna Commercial	$148.45
Rate for Payer: Aetna Medicare	$130.50
Rate for Payer: BCBS Complete	$104.40
Rate for Payer: BCN Commercial	$290.00
Rate for Payer: Cash Price	$208.80
Rate for Payer: Cash Price	$208.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$195.75

PR HIB-HEPB VACCINE FOR INTRAMUSCULAR USE

Professional

Both

$273.00

Service Code	HCPCS 90748
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$204.75
Rate for Payer: Aetna Commercial	$42.90
Rate for Payer: Aetna Medicare	$136.50
Rate for Payer: BCBS Complete	$109.20
Rate for Payer: BCBS Trust/PPO	$42.85
Rate for Payer: BCN Commercial	$0.01
Rate for Payer: Cash Price	$218.40
Rate for Payer: Cash Price	$218.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$204.75

PR HIB PRP-OMP VACCINE 3 DOSE SCHEDULE IM USE

Professional

Both

$38.00

Service Code	HCPCS 90647
Min. Negotiated Rate	$19.00
Max. Negotiated Rate	$31.47
Rate for Payer: Aetna Commercial	$30.53
Rate for Payer: Aetna Medicare	$19.00
Rate for Payer: BCBS Trust/PPO	$31.47
Rate for Payer: BCN Commercial	$29.96
Rate for Payer: Cash Price	$30.40
Rate for Payer: Cash Price	$30.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$28.50

PR HIB PRP-T VACCINE 4 DOSE SCHEDULE IM USE

Professional

Both

$34.00

Service Code	HCPCS 90648
Min. Negotiated Rate	$13.07
Max. Negotiated Rate	$25.50
Rate for Payer: Aetna Commercial	$13.32
Rate for Payer: Aetna Medicare	$17.00
Rate for Payer: BCBS Trust/PPO	$13.17
Rate for Payer: BCN Commercial	$13.07
Rate for Payer: Cash Price	$27.20
Rate for Payer: Cash Price	$27.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$25.50

PR HIB VACCINE, HBOC, IM

Professional

Both

$33.00

Service Code	HCPCS 90645
Min. Negotiated Rate	$13.20
Max. Negotiated Rate	$24.75
Rate for Payer: Aetna Medicare	$16.50
Rate for Payer: BCBS Complete	$13.20
Rate for Payer: Cash Price	$26.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$24.75

PR HIB VACCINE, PRP-D, IM

Professional

Both

$34.00

Service Code	HCPCS 90646
Min. Negotiated Rate	$13.60
Max. Negotiated Rate	$25.50
Rate for Payer: Aetna Medicare	$17.00
Rate for Payer: BCBS Complete	$13.60
Rate for Payer: Cash Price	$27.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$25.50

PR HINGE EXTENSION/FLEX WRIST/F

Professional

Both

$1,557.00

Service Code	HCPCS L3900
Min. Negotiated Rate	$622.80
Max. Negotiated Rate	$1,734.69
Rate for Payer: Aetna Commercial	$887.96
Rate for Payer: Aetna Medicare	$778.50
Rate for Payer: BCBS Complete	$622.80
Rate for Payer: BCN Commercial	$1,734.69
Rate for Payer: Cash Price	$1,245.60
Rate for Payer: Cash Price	$1,245.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,167.75

PR HOME HEALTH CARE SUPERVISION

Professional

Both

$190.00

Service Code	HCPCS G0181
Min. Negotiated Rate	$76.00
Max. Negotiated Rate	$157.36
Rate for Payer: Aetna Commercial	$103.61
Rate for Payer: Aetna Medicare	$95.00
Rate for Payer: BCBS Complete	$76.00
Rate for Payer: BCN Commercial	$157.36
Rate for Payer: Cash Price	$152.00
Rate for Payer: Cash Price	$152.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$142.50
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$145.11
Rate for Payer: Priority Health Narrow/Tiered Network	$145.11

PR HOME/RES VISIT EST PATIENT HIGH MDM 60 MINUTES

Professional

Both

$315.00

Service Code	HCPCS 99350
Min. Negotiated Rate	$157.50
Max. Negotiated Rate	$273.89
Rate for Payer: Aetna Commercial	$175.20
Rate for Payer: Aetna Medicare	$157.50
Rate for Payer: BCN Commercial	$273.89
Rate for Payer: Cash Price	$252.00
Rate for Payer: Cash Price	$252.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$236.25
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$246.37
Rate for Payer: Priority Health Narrow/Tiered Network	$246.37

PR HOME/RES VISIT EST PATIENT LOW MDM 30 MINUTES

Professional

Both

$155.00

Service Code	HCPCS 99348
Min. Negotiated Rate	$77.50
Max. Negotiated Rate	$116.25
Rate for Payer: Aetna Commercial	$82.16
Rate for Payer: Aetna Medicare	$77.50
Rate for Payer: BCN Commercial	$114.04
Rate for Payer: Cash Price	$124.00
Rate for Payer: Cash Price	$124.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$116.25
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$102.57
Rate for Payer: Priority Health Narrow/Tiered Network	$102.57

PR HOME/RES VISIT EST PATIENT MOD MDM 40 MINUTES

Professional

Both

$227.00

Service Code	HCPCS 99349
Min. Negotiated Rate	$113.50
Max. Negotiated Rate	$188.74
Rate for Payer: Aetna Commercial	$126.46
Rate for Payer: Aetna Medicare	$113.50
Rate for Payer: BCN Commercial	$188.74
Rate for Payer: Cash Price	$181.60
Rate for Payer: Cash Price	$181.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$170.25
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$169.76
Rate for Payer: Priority Health Narrow/Tiered Network	$169.76

PR HOME/RES VISIT EST PATIENT SF MDM 20 MINUTES

Professional

Both

$104.00

Service Code	HCPCS 99347
Min. Negotiated Rate	$52.00
Max. Negotiated Rate	$78.00
Rate for Payer: Aetna Commercial	$53.66
Rate for Payer: Aetna Medicare	$52.00
Rate for Payer: BCN Commercial	$67.23
Rate for Payer: Cash Price	$83.20
Rate for Payer: Cash Price	$83.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$78.00
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$60.47
Rate for Payer: Priority Health Narrow/Tiered Network	$60.47

PR HOME/RES VISIT NEW PATIENT HIGH MDM 75 MINUTES

Professional

Both

$416.00

Service Code	HCPCS 99345
Min. Negotiated Rate	$208.00
Max. Negotiated Rate	$312.00
Rate for Payer: Aetna Commercial	$216.48
Rate for Payer: Aetna Medicare	$208.00
Rate for Payer: BCN Commercial	$298.29
Rate for Payer: Cash Price	$332.80
Rate for Payer: Cash Price	$332.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$312.00
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$268.32
Rate for Payer: Priority Health Narrow/Tiered Network	$268.32

PR HOME/RES VISIT NEW PATIENT LOW MDM 30 MINUTES

Professional

Both

$167.00

Service Code	HCPCS 99342
Min. Negotiated Rate	$75.54
Max. Negotiated Rate	$125.25
Rate for Payer: Aetna Commercial	$75.54
Rate for Payer: Aetna Medicare	$83.50
Rate for Payer: BCN Commercial	$116.53
Rate for Payer: Cash Price	$133.60
Rate for Payer: Cash Price	$133.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$125.25
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$104.81
Rate for Payer: Priority Health Narrow/Tiered Network	$104.81

PR HOME/RES VISIT NEW PATIENT MOD MDM 60 MINUTES

Professional

Both

$324.00

Service Code	HCPCS 99344
Min. Negotiated Rate	$162.00
Max. Negotiated Rate	$243.00
Rate for Payer: Aetna Commercial	$177.73
Rate for Payer: Aetna Medicare	$162.00
Rate for Payer: BCN Commercial	$210.65
Rate for Payer: Cash Price	$259.20
Rate for Payer: Cash Price	$259.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$243.00
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$189.48
Rate for Payer: Priority Health Narrow/Tiered Network	$189.48

PR HOME/RES VISIT NEW PATIENT SF MDM 15 MINUTES

Professional

Both

$134.00

Service Code	HCPCS 99341
Min. Negotiated Rate	$53.37
Max. Negotiated Rate	$100.50
Rate for Payer: Aetna Commercial	$53.37
Rate for Payer: Aetna Medicare	$67.00
Rate for Payer: BCN Commercial	$73.20
Rate for Payer: Cash Price	$107.20
Rate for Payer: Cash Price	$107.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$100.50
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$65.85
Rate for Payer: Priority Health Narrow/Tiered Network	$65.85

PR HOME SLEEP TEST/TYPE 3 PORTA

Professional

Both

$366.00

Service Code	HCPCS G0399
Min. Negotiated Rate	$131.80
Max. Negotiated Rate	$274.50
Rate for Payer: Aetna Commercial	$187.42
Rate for Payer: Aetna Medicare	$183.00
Rate for Payer: BCBS Complete	$146.40
Rate for Payer: BCN Commercial	$173.02
Rate for Payer: Cash Price	$292.80
Rate for Payer: Cash Price	$292.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$274.50
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$131.80
Rate for Payer: Priority Health Narrow/Tiered Network	$131.80

PR HOME SLEEP TEST/TYPE 4 PORTA

Professional

Both

$215.00

Service Code	HCPCS G0400
Min. Negotiated Rate	$86.00
Max. Negotiated Rate	$173.02
Rate for Payer: Aetna Commercial	$162.24
Rate for Payer: Aetna Commercial	$162.24
Rate for Payer: Aetna Commercial	$162.24
Rate for Payer: Aetna Medicare	$75.00
Rate for Payer: Aetna Medicare	$107.50
Rate for Payer: Aetna Medicare	$183.00
Rate for Payer: BCBS Complete	$86.00
Rate for Payer: BCBS Complete	$60.00
Rate for Payer: BCBS Complete	$146.40
Rate for Payer: BCN Commercial	$173.02
Rate for Payer: BCN Commercial	$173.02
Rate for Payer: BCN Commercial	$173.02
Rate for Payer: Cash Price	$172.00
Rate for Payer: Cash Price	$120.00
Rate for Payer: Cash Price	$120.00
Rate for Payer: Cash Price	$172.00
Rate for Payer: Cash Price	$292.80
Rate for Payer: Cash Price	$292.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$112.50
Rate for Payer: Opus (Opus Packaging Group) HMA	$161.25
Rate for Payer: Opus (Opus Packaging Group) HMA	$274.50
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$157.07
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$157.07
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$157.07
Rate for Payer: Priority Health Narrow/Tiered Network	$157.07
Rate for Payer: Priority Health Narrow/Tiered Network	$157.07
Rate for Payer: Priority Health Narrow/Tiered Network	$157.07

PR HOME VENTILATOR MGMT CARE OVERSIGHT 30 MIN/>

Professional

Both

$197.00

Service Code	HCPCS 94005
Min. Negotiated Rate	$78.80
Max. Negotiated Rate	$147.75
Rate for Payer: Aetna Commercial	$100.62
Rate for Payer: Aetna Medicare	$98.50
Rate for Payer: BCBS Complete	$78.80
Rate for Payer: BCN Commercial	$134.95
Rate for Payer: Cash Price	$157.60
Rate for Payer: Cash Price	$157.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$147.75
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$124.46
Rate for Payer: Priority Health Narrow/Tiered Network	$124.46

Know your out-of-pocket cost for care.

All Charges