Bronson Lakeview Hospital

All Charges

Charge

Type

Setting

Price

PR I&D VULVA/PERINEAL ABSCESS

Professional

Both

$286.00

Service Code	HCPCS 56405
Min. Negotiated Rate	$74.55
Max. Negotiated Rate	$214.50
Rate for Payer: Aetna Commercial	$146.26
Rate for Payer: Aetna Medicare	$143.00
Rate for Payer: BCBS Complete	$78.28
Rate for Payer: BCN Commercial	$191.72
Rate for Payer: Cash Price	$228.80
Rate for Payer: Cash Price	$228.80
Rate for Payer: Mclaren Medicaid	$74.55
Rate for Payer: Meridian Medicaid	$78.28
Rate for Payer: Opus (Opus Packaging Group) HMA	$214.50
Rate for Payer: Priority Health Choice Medicaid	$74.55
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$194.17
Rate for Payer: Priority Health Narrow/Tiered Network	$194.17
Rate for Payer: UHC Medicaid	$74.55
Rate for Payer: UHCCP Medicaid	$74.55

PR IIV3 VACCINE SPLIT VIRUS 0.25 ML DOSAGE IM USE

Professional

Both

$44.00

Service Code	HCPCS 90657
Min. Negotiated Rate	$9.50
Max. Negotiated Rate	$33.00
Rate for Payer: Aetna Commercial	$9.50
Rate for Payer: Aetna Medicare	$22.00
Rate for Payer: BCBS Trust/PPO	$9.74
Rate for Payer: BCN Commercial	$9.75
Rate for Payer: Cash Price	$35.20
Rate for Payer: Cash Price	$35.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$33.00

PR IIV3 VACCINE SPLIT VIRUS 0.5 ML DOSAGE IM USE

Professional

Both

$44.00

Service Code	HCPCS 90658
Min. Negotiated Rate	$16.32
Max. Negotiated Rate	$33.00
Rate for Payer: Aetna Commercial	$16.32
Rate for Payer: Aetna Medicare	$22.00
Rate for Payer: BCBS Trust/PPO	$19.48
Rate for Payer: BCN Commercial	$19.51
Rate for Payer: Cash Price	$35.20
Rate for Payer: Cash Price	$35.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$33.00

PR IIV3 VACC PRESERVATIVE FREE 0.5 ML DOSAGE IM USE

Professional

Both

$44.00

Service Code	HCPCS 90656
Min. Negotiated Rate	$17.69
Max. Negotiated Rate	$33.00
Rate for Payer: Aetna Commercial	$17.69
Rate for Payer: Aetna Medicare	$22.00
Rate for Payer: BCBS Trust/PPO	$20.49
Rate for Payer: BCN Commercial	$21.12
Rate for Payer: Cash Price	$35.20
Rate for Payer: Cash Price	$35.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$33.00

PR IIV3 VACC PRESRV FREE 0.25 ML DOSAGE IM USE

Professional

Both

$24.00

Service Code	HCPCS 90655
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$20.49
Rate for Payer: Aetna Commercial	$16.30
Rate for Payer: Aetna Medicare	$12.00
Rate for Payer: BCBS Trust/PPO	$20.49
Rate for Payer: BCN Commercial	$0.01
Rate for Payer: Cash Price	$19.20
Rate for Payer: Cash Price	$19.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$18.00

PR IIV4 VACC PRESRV FREE 0.5 ML DOS FOR IM USE

Professional

Both

$27.00

Service Code	HCPCS 90686
Min. Negotiated Rate	$13.50
Max. Negotiated Rate	$22.65
Rate for Payer: Aetna Commercial	$22.35
Rate for Payer: Aetna Medicare	$13.50
Rate for Payer: BCBS Trust/PPO	$19.73
Rate for Payer: BCN Commercial	$22.65
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 IIV4 VACC PRSRV FREE 0.25 ML DOS FOR IM USE

Professional

Both

$27.00

Service Code	HCPCS 90685
Min. Negotiated Rate	$13.50
Max. Negotiated Rate	$22.05
Rate for Payer: Aetna Commercial	$19.36
Rate for Payer: Aetna Medicare	$13.50
Rate for Payer: BCBS Trust/PPO	$22.05
Rate for Payer: BCN Commercial	$22.05
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 IIV4 VACC SPLIT VIRUS 0.25 ML DOS FOR IM USE

Professional

Both

$27.00

Service Code	HCPCS 90687
Min. Negotiated Rate	$9.22
Max. Negotiated Rate	$20.25
Rate for Payer: Aetna Commercial	$10.44
Rate for Payer: Aetna Medicare	$13.50
Rate for Payer: BCBS Trust/PPO	$9.22
Rate for Payer: BCN Commercial	$10.78
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 IIV4 VACC SPLIT VIRUS 0.5 ML DOS FOR IM USE

Professional

Both

$27.00

Service Code	HCPCS 90688
Min. Negotiated Rate	$13.50
Max. Negotiated Rate	$21.56
Rate for Payer: Aetna Commercial	$20.88
Rate for Payer: Aetna Medicare	$13.50
Rate for Payer: BCBS Trust/PPO	$18.44
Rate for Payer: BCN Commercial	$21.56
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 IIV ADJUVANTED VACCINE FOR INTRAMUSCULAR USE

Professional

Both

$63.00

Service Code	HCPCS 90653
Min. Negotiated Rate	$31.50
Max. Negotiated Rate	$86.23
Rate for Payer: Aetna Commercial	$54.02
Rate for Payer: Aetna Medicare	$31.50
Rate for Payer: BCBS Trust/PPO	$86.23
Rate for Payer: BCN Commercial	$72.06
Rate for Payer: Cash Price	$50.40
Rate for Payer: Cash Price	$50.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$47.25

PR IIV VACCINE PRESERV FREE INCREASED AG CONTENT IM

Professional

Both

$114.00

Service Code	HCPCS 90662
Min. Negotiated Rate	$57.00
Max. Negotiated Rate	$86.23
Rate for Payer: Aetna Commercial	$73.40
Rate for Payer: Aetna Medicare	$57.00
Rate for Payer: BCBS Trust/PPO	$86.23
Rate for Payer: BCN Commercial	$72.06
Rate for Payer: Cash Price	$91.20
Rate for Payer: Cash Price	$91.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$85.50

PR ILEOSCOPY STOMA W/BALLOON DILATION

Professional

Both

$242.00

Service Code	HCPCS 44381
Min. Negotiated Rate	$49.42
Max. Negotiated Rate	$181.50
Rate for Payer: Aetna Commercial	$110.61
Rate for Payer: Aetna Medicare	$121.00
Rate for Payer: BCBS Complete	$51.89
Rate for Payer: BCN Commercial	$124.99
Rate for Payer: Cash Price	$193.60
Rate for Payer: Cash Price	$193.60
Rate for Payer: Mclaren Medicaid	$49.42
Rate for Payer: Meridian Medicaid	$51.89
Rate for Payer: Opus (Opus Packaging Group) HMA	$181.50
Rate for Payer: Priority Health Choice Medicaid	$49.42
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$152.30
Rate for Payer: Priority Health Narrow/Tiered Network	$152.30
Rate for Payer: UHC Medicaid	$49.42
Rate for Payer: UHCCP Medicaid	$49.42

PR ILEOSCOPY STOMA W/BX SINGLE/MULTIPLE

Professional

Both

$965.00

Service Code	HCPCS 44382
Min. Negotiated Rate	$43.24
Max. Negotiated Rate	$723.75
Rate for Payer: Aetna Commercial	$97.19
Rate for Payer: Aetna Medicare	$482.50
Rate for Payer: BCBS Complete	$45.40
Rate for Payer: BCN Commercial	$110.05
Rate for Payer: Cash Price	$772.00
Rate for Payer: Cash Price	$772.00
Rate for Payer: Mclaren Medicaid	$43.24
Rate for Payer: Meridian Medicaid	$45.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$723.75
Rate for Payer: Priority Health Choice Medicaid	$43.24
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$134.10
Rate for Payer: Priority Health Narrow/Tiered Network	$134.10
Rate for Payer: UHC Medicaid	$43.24
Rate for Payer: UHCCP Medicaid	$43.24

PR ILEOSCOPY STOMA W/PLMT OF ENDOSCOPIC STENT

Professional

Both

$247.00

Service Code	HCPCS 44384
Min. Negotiated Rate	$86.05
Max. Negotiated Rate	$275.46
Rate for Payer: Aetna Commercial	$205.72
Rate for Payer: Aetna Medicare	$123.50
Rate for Payer: BCBS Complete	$90.35
Rate for Payer: BCN Commercial	$226.08
Rate for Payer: Cash Price	$197.60
Rate for Payer: Cash Price	$197.60
Rate for Payer: Mclaren Medicaid	$86.05
Rate for Payer: Meridian Medicaid	$90.35
Rate for Payer: Opus (Opus Packaging Group) HMA	$185.25
Rate for Payer: Priority Health Choice Medicaid	$86.05
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$275.46
Rate for Payer: Priority Health Narrow/Tiered Network	$275.46
Rate for Payer: UHC Medicaid	$86.05
Rate for Payer: UHCCP Medicaid	$86.05

PR ILEOSCOPY THRU STOMA DX W/COLLJ SPEC WHEN PRFMD

Professional

Both

$863.00

Service Code	HCPCS 44380
Min. Negotiated Rate	$33.87
Max. Negotiated Rate	$647.25
Rate for Payer: Aetna Commercial	$74.35
Rate for Payer: Aetna Medicare	$431.50
Rate for Payer: BCBS Complete	$35.56
Rate for Payer: BCN Commercial	$86.15
Rate for Payer: Cash Price	$690.40
Rate for Payer: Cash Price	$690.40
Rate for Payer: Mclaren Medicaid	$33.87
Rate for Payer: Meridian Medicaid	$35.56
Rate for Payer: Opus (Opus Packaging Group) HMA	$647.25
Rate for Payer: Priority Health Choice Medicaid	$33.87
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$104.97
Rate for Payer: Priority Health Narrow/Tiered Network	$104.97
Rate for Payer: UHC Medicaid	$33.87
Rate for Payer: UHCCP Medicaid	$33.87

PR ILEOSCOPY,THRU STOMA,TRANSENDO STENT

Professional

Both

$1,120.00

Service Code	HCPCS 44383
Min. Negotiated Rate	$448.00
Max. Negotiated Rate	$840.00
Rate for Payer: Aetna Medicare	$560.00
Rate for Payer: BCBS Complete	$448.00
Rate for Payer: Cash Price	$896.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$840.00

PR ILEOSTOMY/JEJUNOSTOMY NON-TUBE

Professional

Both

$2,631.00

Service Code	HCPCS 44310
Min. Negotiated Rate	$617.06
Max. Negotiated Rate	$1,973.25
Rate for Payer: Aetna Commercial	$1,396.74
Rate for Payer: Aetna Medicare	$1,315.50
Rate for Payer: BCBS Complete	$647.91
Rate for Payer: BCN Commercial	$1,556.69
Rate for Payer: Cash Price	$2,104.80
Rate for Payer: Cash Price	$2,104.80
Rate for Payer: Mclaren Medicaid	$617.06
Rate for Payer: Meridian Medicaid	$647.91
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,973.25
Rate for Payer: Priority Health Choice Medicaid	$617.06
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$1,896.72
Rate for Payer: Priority Health Narrow/Tiered Network	$1,896.72
Rate for Payer: UHC Medicaid	$617.06
Rate for Payer: UHCCP Medicaid	$617.06

PR ILIAC ART ANGIO,CARDIAC CATH

Professional

Both

$37.00

Service Code	HCPCS G0278
Min. Negotiated Rate	$14.80
Max. Negotiated Rate	$27.75
Rate for Payer: Aetna Commercial	$17.94
Rate for Payer: Aetna Medicare	$18.50
Rate for Payer: BCBS Complete	$14.80
Rate for Payer: BCN Commercial	$19.42
Rate for Payer: Cash Price	$29.60
Rate for Payer: Cash Price	$29.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$27.75
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$19.58
Rate for Payer: Priority Health Narrow/Tiered Network	$19.58

PR IM ADM INTRANSL/ORAL 1 VACCINE

Professional

Both

$34.00

Service Code	HCPCS 90473
Min. Negotiated Rate	$5.00
Max. Negotiated Rate	$26.75
Rate for Payer: Aetna Commercial	$5.00
Rate for Payer: Aetna Medicare	$17.00
Rate for Payer: BCN Commercial	$19.64
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	$26.75
Rate for Payer: Priority Health Narrow/Tiered Network	$26.75

PR IM ADM INTRANSL/ORAL EA VACCINE

Professional

Both

$24.00

Service Code	HCPCS 90474
Min. Negotiated Rate	$5.00
Max. Negotiated Rate	$18.00
Rate for Payer: Aetna Commercial	$5.00
Rate for Payer: Aetna Medicare	$12.00
Rate for Payer: BCN Commercial	$14.14
Rate for Payer: Cash Price	$19.20
Rate for Payer: Cash Price	$19.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$18.00
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$16.53
Rate for Payer: Priority Health Narrow/Tiered Network	$16.53

PR IM ADM PRQ ID SUBQ/IM NJXS 1 VACCINE

Professional

Both

$34.00

Service Code	HCPCS 90471
Min. Negotiated Rate	$12.00
Max. Negotiated Rate	$27.07
Rate for Payer: Aetna Commercial	$12.00
Rate for Payer: Aetna Medicare	$17.00
Rate for Payer: BCN Commercial	$27.07
Rate for Payer: Cash Price	$27.20
Rate for Payer: Cash Price	$27.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$25.50
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$26.75
Rate for Payer: Priority Health Narrow/Tiered Network	$26.75

PR IM ADM PRQ ID SUBQ/IM NJXS EA VACCINE

Professional

Both

$24.00

Service Code	HCPCS 90472
Min. Negotiated Rate	$7.00
Max. Negotiated Rate	$20.20
Rate for Payer: Aetna Commercial	$7.00
Rate for Payer: Aetna Medicare	$12.00
Rate for Payer: BCN Commercial	$17.28
Rate for Payer: Cash Price	$19.20
Rate for Payer: Cash Price	$19.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$18.00
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$20.20
Rate for Payer: Priority Health Narrow/Tiered Network	$20.20

PR IM ADM THRU 18YR ANY RTE 1ST/ONLY COMPT VAC/TOX

Professional

Both

$37.00

Service Code	HCPCS 90460
Min. Negotiated Rate	$12.00
Max. Negotiated Rate	$27.75
Rate for Payer: Aetna Commercial	$12.00
Rate for Payer: Aetna Medicare	$18.50
Rate for Payer: BCN Commercial	$25.96
Rate for Payer: Cash Price	$29.60
Rate for Payer: Cash Price	$29.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$27.75
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$26.75
Rate for Payer: Priority Health Narrow/Tiered Network	$26.75

PR IM ADM THRU 18YR ANY RTE ADDL VAC/TOX COMPT

Professional

Both

$24.00

Service Code	HCPCS 90461
Min. Negotiated Rate	$7.00
Max. Negotiated Rate	$18.00
Rate for Payer: Aetna Commercial	$7.00
Rate for Payer: Aetna Medicare	$12.00
Rate for Payer: BCN Commercial	$13.80
Rate for Payer: Cash Price	$19.20
Rate for Payer: Cash Price	$19.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$18.00
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$11.94
Rate for Payer: Priority Health Narrow/Tiered Network	$11.94

PR IMBRICATION DIAPHRAGM EVENTRATION

Professional

Both

$5,582.00

Service Code	HCPCS 39545
Min. Negotiated Rate	$556.57
Max. Negotiated Rate	$4,186.50
Rate for Payer: Aetna Commercial	$914.62
Rate for Payer: Aetna Medicare	$2,791.00
Rate for Payer: BCBS Complete	$584.40
Rate for Payer: BCN Commercial	$1,337.08
Rate for Payer: Cash Price	$4,465.60
Rate for Payer: Cash Price	$4,465.60
Rate for Payer: Mclaren Medicaid	$556.57
Rate for Payer: Meridian Medicaid	$584.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$4,186.50
Rate for Payer: Priority Health Choice Medicaid	$556.57
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$1,437.85
Rate for Payer: Priority Health Narrow/Tiered Network	$1,437.85
Rate for Payer: UHC Medicaid	$556.57
Rate for Payer: UHCCP Medicaid	$556.57

Know your out-of-pocket cost for care.

All Charges