Bronson Lakeview Hospital

All Charges

Charge

Type

Setting

Price

PR IV INFUSION THERAPY/PROPHYLAXIS /DX 1ST TO 1 HR

Professional

Both

$136.00

Service Code	HCPCS 96365
Min. Negotiated Rate	$68.00
Max. Negotiated Rate	$102.00
Rate for Payer: Aetna Commercial	$75.96
Rate for Payer: Aetna Medicare	$68.00
Rate for Payer: BCN Commercial	$89.14
Rate for Payer: Cash Price	$108.80
Rate for Payer: Cash Price	$108.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$102.00
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$82.20
Rate for Payer: Priority Health Narrow/Tiered Network	$82.20

PR IV INFUSION THERAPY PROPHYLAXIS/DX EA HOUR

Professional

Both

$39.00

Service Code	HCPCS 96366
Min. Negotiated Rate	$19.50
Max. Negotiated Rate	$29.88
Rate for Payer: Aetna Commercial	$23.44
Rate for Payer: Aetna Medicare	$19.50
Rate for Payer: BCN Commercial	$29.88
Rate for Payer: Cash Price	$31.20
Rate for Payer: Cash Price	$31.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$29.25
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$27.56
Rate for Payer: Priority Health Narrow/Tiered Network	$27.56

PR IV INFUSION THER PROPH ADDL SEQUENTIAL TO 1 HR

Professional

Both

$60.00

Service Code	HCPCS 96367
Min. Negotiated Rate	$30.00
Max. Negotiated Rate	$45.00
Rate for Payer: Aetna Commercial	$33.47
Rate for Payer: Aetna Medicare	$30.00
Rate for Payer: BCN Commercial	$40.83
Rate for Payer: Cash Price	$48.00
Rate for Payer: Cash Price	$48.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$45.00
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$37.65
Rate for Payer: Priority Health Narrow/Tiered Network	$37.65

PR IV INJECTION AGENT TEST VASCULAR FLOW FLAP/GRAFT

Professional

Both

$237.00

Service Code	HCPCS 15860
Min. Negotiated Rate	$59.43
Max. Negotiated Rate	$177.75
Rate for Payer: Aetna Commercial	$116.64
Rate for Payer: Aetna Medicare	$118.50
Rate for Payer: BCBS Complete	$62.40
Rate for Payer: BCN Commercial	$158.86
Rate for Payer: Cash Price	$189.60
Rate for Payer: Cash Price	$189.60
Rate for Payer: Mclaren Medicaid	$59.43
Rate for Payer: Meridian Medicaid	$62.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$177.75
Rate for Payer: Priority Health Choice Medicaid	$59.43
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$145.40
Rate for Payer: Priority Health Narrow/Tiered Network	$145.40
Rate for Payer: UHC Medicaid	$59.43
Rate for Payer: UHCCP Medicaid	$59.43

PR IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS

Professional

Both

$41.00

Service Code	HCPCS 96368
Min. Negotiated Rate	$20.50
Max. Negotiated Rate	$30.75
Rate for Payer: Aetna Commercial	$22.34
Rate for Payer: Aetna Medicare	$20.50
Rate for Payer: BCN Commercial	$28.39
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	$26.18
Rate for Payer: Priority Health Narrow/Tiered Network	$26.18

PR IV ULTRASOUND,FIRST VESSEL

Professional

Both

$315.00

Service Code	HCPCS 37250
Min. Negotiated Rate	$126.00
Max. Negotiated Rate	$236.25
Rate for Payer: Aetna Medicare	$157.50
Rate for Payer: BCBS Complete	$126.00
Rate for Payer: Cash Price	$252.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$236.25

PR KETOROLAC TROMETHAMINE INJ

Professional

Both

$10.00

Service Code	HCPCS J1885
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$7.50
Rate for Payer: Aetna Commercial	$0.50
Rate for Payer: Aetna Medicare	$5.00
Rate for Payer: BCBS Trust/PPO	$0.07
Rate for Payer: BCN Commercial	$0.10
Rate for Payer: Cash Price	$8.00
Rate for Payer: Cash Price	$8.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$7.50

PR KO IMMOB CANVAS LONG PRE OTS

Professional

Both

$84.00

Service Code	HCPCS L1830
Min. Negotiated Rate	$33.60
Max. Negotiated Rate	$66.88
Rate for Payer: Aetna Commercial	$42.62
Rate for Payer: Aetna Medicare	$42.00
Rate for Payer: BCBS Complete	$33.60
Rate for Payer: BCN Commercial	$66.88
Rate for Payer: Cash Price	$67.20
Rate for Payer: Cash Price	$67.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$63.00

PR KYBELLA

Professional

Both

$630.00

Hospital Revenue Code	990
Min. Negotiated Rate	$252.00
Max. Negotiated Rate	$472.50
Rate for Payer: Aetna Medicare	$315.00
Rate for Payer: BCBS Complete	$252.00
Rate for Payer: Cash Price	$504.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$472.50

PR KYLEENA, 19.5 MG

Professional

Both

$903.00

Service Code	HCPCS Q9984
Min. Negotiated Rate	$361.20
Max. Negotiated Rate	$677.25
Rate for Payer: Aetna Medicare	$451.50
Rate for Payer: BCBS Complete	$361.20
Rate for Payer: Cash Price	$722.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$677.25

PR KYLEENA, 19.5 MG

Professional

Both

$1,516.00

Service Code	HCPCS J7296
Min. Negotiated Rate	$758.00
Max. Negotiated Rate	$1,351.89
Rate for Payer: Aetna Commercial	$1,101.70
Rate for Payer: Aetna Medicare	$758.00
Rate for Payer: BCBS Complete	$1,351.89
Rate for Payer: BCBS Trust/PPO	$1,235.57
Rate for Payer: BCN Commercial	$1,236.73
Rate for Payer: Cash Price	$1,212.80
Rate for Payer: Cash Price	$1,212.80
Rate for Payer: Mclaren Medicaid	$1,287.51
Rate for Payer: Meridian Medicaid	$1,351.89
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,137.00
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 KYPHECTOMY SINGLE OR TWO SEGMENTS

Professional

Both

$13,314.00

Service Code	HCPCS 22818
Min. Negotiated Rate	$1,219.21
Max. Negotiated Rate	$9,985.50
Rate for Payer: Aetna Commercial	$2,890.03
Rate for Payer: Aetna Medicare	$6,657.00
Rate for Payer: BCBS Complete	$1,280.17
Rate for Payer: BCN Commercial	$3,230.90
Rate for Payer: Cash Price	$10,651.20
Rate for Payer: Cash Price	$10,651.20
Rate for Payer: Mclaren Medicaid	$1,219.21
Rate for Payer: Meridian Medicaid	$1,280.17
Rate for Payer: Opus (Opus Packaging Group) HMA	$9,985.50
Rate for Payer: Priority Health Choice Medicaid	$1,219.21
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$3,453.74
Rate for Payer: Priority Health Narrow/Tiered Network	$3,453.74
Rate for Payer: UHC Medicaid	$1,219.21
Rate for Payer: UHCCP Medicaid	$1,219.21

PR LABYRINTHOTOMY TRANSCANAL

Professional

Both

$420.00

Service Code	HCPCS 69801
Min. Negotiated Rate	$68.59
Max. Negotiated Rate	$315.00
Rate for Payer: Aetna Commercial	$139.33
Rate for Payer: Aetna Medicare	$210.00
Rate for Payer: BCBS Complete	$72.02
Rate for Payer: BCN Commercial	$186.75
Rate for Payer: Cash Price	$336.00
Rate for Payer: Cash Price	$336.00
Rate for Payer: Mclaren Medicaid	$68.59
Rate for Payer: Meridian Medicaid	$72.02
Rate for Payer: Opus (Opus Packaging Group) HMA	$315.00
Rate for Payer: Priority Health Choice Medicaid	$68.59
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$184.52
Rate for Payer: Priority Health Narrow/Tiered Network	$184.52
Rate for Payer: UHC Medicaid	$68.59
Rate for Payer: UHCCP Medicaid	$68.59

PR LAIV3 VACCINE LIVE FOR INTRANASAL USE

Professional

Both

$71.00

Service Code	HCPCS 90660
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$53.25
Rate for Payer: Aetna Commercial	$0.01
Rate for Payer: Aetna Medicare	$35.50
Rate for Payer: BCBS Trust/PPO	$26.19
Rate for Payer: BCN Commercial	$24.91
Rate for Payer: Cash Price	$56.80
Rate for Payer: Cash Price	$56.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$53.25

PR LAIV4 VACCINE FOR INTRANASAL USE

Professional

Both

$33.00

Service Code	HCPCS 90672
Min. Negotiated Rate	$16.50
Max. Negotiated Rate	$27.79
Rate for Payer: Aetna Commercial	$27.79
Rate for Payer: Aetna Medicare	$16.50
Rate for Payer: BCBS Trust/PPO	$24.50
Rate for Payer: BCN Commercial	$23.98
Rate for Payer: Cash Price	$26.40
Rate for Payer: Cash Price	$26.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$24.75

PR LAM BX/EXC ISPI NEO IDRL IMED CERVICAL

Professional

Both

$8,508.00

Service Code	HCPCS 63285
Min. Negotiated Rate	$1,609.64
Max. Negotiated Rate	$6,381.00
Rate for Payer: Aetna Commercial	$3,380.35
Rate for Payer: Aetna Medicare	$4,254.00
Rate for Payer: BCBS Complete	$1,690.12
Rate for Payer: BCN Commercial	$4,368.34
Rate for Payer: Cash Price	$6,806.40
Rate for Payer: Cash Price	$6,806.40
Rate for Payer: Mclaren Medicaid	$1,609.64
Rate for Payer: Meridian Medicaid	$1,690.12
Rate for Payer: Opus (Opus Packaging Group) HMA	$6,381.00
Rate for Payer: Priority Health Choice Medicaid	$1,609.64
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$4,618.49
Rate for Payer: Priority Health Narrow/Tiered Network	$4,618.49
Rate for Payer: UHC Medicaid	$1,609.64
Rate for Payer: UHCCP Medicaid	$1,609.64

PR LAM BX/EXC ISPI NEO IDRL IMED THORACIC

Professional

Both

$8,526.00

Service Code	HCPCS 63286
Min. Negotiated Rate	$1,590.68
Max. Negotiated Rate	$6,394.50
Rate for Payer: Aetna Commercial	$3,337.98
Rate for Payer: Aetna Medicare	$4,263.00
Rate for Payer: BCBS Complete	$1,670.21
Rate for Payer: BCN Commercial	$4,318.56
Rate for Payer: Cash Price	$6,820.80
Rate for Payer: Cash Price	$6,820.80
Rate for Payer: Mclaren Medicaid	$1,590.68
Rate for Payer: Meridian Medicaid	$1,670.21
Rate for Payer: Opus (Opus Packaging Group) HMA	$6,394.50
Rate for Payer: Priority Health Choice Medicaid	$1,590.68
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$4,565.85
Rate for Payer: Priority Health Narrow/Tiered Network	$4,565.85
Rate for Payer: UHC Medicaid	$1,590.68
Rate for Payer: UHCCP Medicaid	$1,590.68

PR LAM BX/EXC ISPI NEO IDRL IMED THORACOLMBR

Professional

Both

$9,011.00

Service Code	HCPCS 63287
Min. Negotiated Rate	$1,684.19
Max. Negotiated Rate	$6,758.25
Rate for Payer: Aetna Commercial	$3,546.68
Rate for Payer: Aetna Medicare	$4,505.50
Rate for Payer: BCBS Complete	$1,768.40
Rate for Payer: BCN Commercial	$4,578.41
Rate for Payer: Cash Price	$7,208.80
Rate for Payer: Cash Price	$7,208.80
Rate for Payer: Mclaren Medicaid	$1,684.19
Rate for Payer: Meridian Medicaid	$1,768.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$6,758.25
Rate for Payer: Priority Health Choice Medicaid	$1,684.19
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$4,840.59
Rate for Payer: Priority Health Narrow/Tiered Network	$4,840.59
Rate for Payer: UHC Medicaid	$1,684.19
Rate for Payer: UHCCP Medicaid	$1,684.19

PR LAM BX/EXC ISPI NEO IDRL SACRAL

Professional

Both

$6,474.00

Service Code	HCPCS 63283
Min. Negotiated Rate	$1,194.08
Max. Negotiated Rate	$4,855.50
Rate for Payer: Aetna Commercial	$2,457.79
Rate for Payer: Aetna Medicare	$3,237.00
Rate for Payer: BCBS Complete	$1,253.78
Rate for Payer: BCN Commercial	$2,906.72
Rate for Payer: Cash Price	$5,179.20
Rate for Payer: Cash Price	$5,179.20
Rate for Payer: Mclaren Medicaid	$1,194.08
Rate for Payer: Meridian Medicaid	$1,253.78
Rate for Payer: Opus (Opus Packaging Group) HMA	$4,855.50
Rate for Payer: Priority Health Choice Medicaid	$1,194.08
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$3,376.10
Rate for Payer: Priority Health Narrow/Tiered Network	$3,376.10
Rate for Payer: UHC Medicaid	$1,194.08
Rate for Payer: UHCCP Medicaid	$1,194.08

PR LAM BX/EXC ISPI NEO IDRL XMED CERVICAL

Professional

Both

$7,817.00

Service Code	HCPCS 63280
Min. Negotiated Rate	$1,315.28
Max. Negotiated Rate	$5,862.75
Rate for Payer: Aetna Commercial	$2,742.34
Rate for Payer: Aetna Medicare	$3,908.50
Rate for Payer: BCBS Complete	$1,381.04
Rate for Payer: BCN Commercial	$3,537.89
Rate for Payer: Cash Price	$6,253.60
Rate for Payer: Cash Price	$6,253.60
Rate for Payer: Mclaren Medicaid	$1,315.28
Rate for Payer: Meridian Medicaid	$1,381.04
Rate for Payer: Opus (Opus Packaging Group) HMA	$5,862.75
Rate for Payer: Priority Health Choice Medicaid	$1,315.28
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$3,740.49
Rate for Payer: Priority Health Narrow/Tiered Network	$3,740.49
Rate for Payer: UHC Medicaid	$1,315.28
Rate for Payer: UHCCP Medicaid	$1,315.28

PR LAM BX/EXC ISPI NEO IDRL XMED LUMBAR

Professional

Both

$8,241.00

Service Code	HCPCS 63282
Min. Negotiated Rate	$1,235.83
Max. Negotiated Rate	$6,180.75
Rate for Payer: Aetna Commercial	$2,559.02
Rate for Payer: Aetna Medicare	$4,120.50
Rate for Payer: BCBS Complete	$1,297.62
Rate for Payer: BCN Commercial	$3,323.44
Rate for Payer: Cash Price	$6,592.80
Rate for Payer: Cash Price	$6,592.80
Rate for Payer: Mclaren Medicaid	$1,235.83
Rate for Payer: Meridian Medicaid	$1,297.62
Rate for Payer: Opus (Opus Packaging Group) HMA	$6,180.75
Rate for Payer: Priority Health Choice Medicaid	$1,235.83
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$3,513.75
Rate for Payer: Priority Health Narrow/Tiered Network	$3,513.75
Rate for Payer: UHC Medicaid	$1,235.83
Rate for Payer: UHCCP Medicaid	$1,235.83

PR LAM BX/EXC ISPI NEO IDRL XMED THORACIC

Professional

Both

$7,655.00

Service Code	HCPCS 63281
Min. Negotiated Rate	$1,305.05
Max. Negotiated Rate	$5,741.25
Rate for Payer: Aetna Commercial	$2,712.92
Rate for Payer: Aetna Medicare	$3,827.50
Rate for Payer: BCBS Complete	$1,370.30
Rate for Payer: BCN Commercial	$3,512.18
Rate for Payer: Cash Price	$6,124.00
Rate for Payer: Cash Price	$6,124.00
Rate for Payer: Mclaren Medicaid	$1,305.05
Rate for Payer: Meridian Medicaid	$1,370.30
Rate for Payer: Opus (Opus Packaging Group) HMA	$5,741.25
Rate for Payer: Priority Health Choice Medicaid	$1,305.05
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$3,713.31
Rate for Payer: Priority Health Narrow/Tiered Network	$3,713.31
Rate for Payer: UHC Medicaid	$1,305.05
Rate for Payer: UHCCP Medicaid	$1,305.05

PR LAM BX/EXC ISPI NEO XDRL-IDRL LES ANY LVL

Professional

Both

$9,664.00

Service Code	HCPCS 63290
Min. Negotiated Rate	$1,711.88
Max. Negotiated Rate	$7,248.00
Rate for Payer: Aetna Commercial	$3,607.11
Rate for Payer: Aetna Medicare	$4,832.00
Rate for Payer: BCBS Complete	$1,797.47
Rate for Payer: BCN Commercial	$4,655.55
Rate for Payer: Cash Price	$7,731.20
Rate for Payer: Cash Price	$7,731.20
Rate for Payer: Mclaren Medicaid	$1,711.88
Rate for Payer: Meridian Medicaid	$1,797.47
Rate for Payer: Opus (Opus Packaging Group) HMA	$7,248.00
Rate for Payer: Priority Health Choice Medicaid	$1,711.88
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$4,922.15
Rate for Payer: Priority Health Narrow/Tiered Network	$4,922.15
Rate for Payer: UHC Medicaid	$1,711.88
Rate for Payer: UHCCP Medicaid	$1,711.88

PR LAM EXC/EVAC ISPI LESION OTH/THN NEO XDRL LUMBAR

Professional

Both

$5,581.00

Service Code	HCPCS 63267
Min. Negotiated Rate	$843.48
Max. Negotiated Rate	$4,185.75
Rate for Payer: Aetna Commercial	$1,771.05
Rate for Payer: Aetna Medicare	$2,790.50
Rate for Payer: BCBS Complete	$885.65
Rate for Payer: BCN Commercial	$2,296.59
Rate for Payer: Cash Price	$4,464.80
Rate for Payer: Cash Price	$4,464.80
Rate for Payer: Mclaren Medicaid	$843.48
Rate for Payer: Meridian Medicaid	$885.65
Rate for Payer: Opus (Opus Packaging Group) HMA	$4,185.75
Rate for Payer: Priority Health Choice Medicaid	$843.48
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$2,428.11
Rate for Payer: Priority Health Narrow/Tiered Network	$2,428.11
Rate for Payer: UHC Medicaid	$843.48
Rate for Payer: UHCCP Medicaid	$843.48

PR LAM EXC/EVAC ISPI LES OTH/THN NEO XDRL CERVICAL

Professional

Both

$5,994.00

Service Code	HCPCS 63265
Min. Negotiated Rate	$1,029.00
Max. Negotiated Rate	$4,495.50
Rate for Payer: Aetna Commercial	$2,154.82
Rate for Payer: Aetna Medicare	$2,997.00
Rate for Payer: BCBS Complete	$1,080.45
Rate for Payer: BCN Commercial	$2,784.58
Rate for Payer: Cash Price	$4,795.20
Rate for Payer: Cash Price	$4,795.20
Rate for Payer: Mclaren Medicaid	$1,029.00
Rate for Payer: Meridian Medicaid	$1,080.45
Rate for Payer: Opus (Opus Packaging Group) HMA	$4,495.50
Rate for Payer: Priority Health Choice Medicaid	$1,029.00
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$2,944.04
Rate for Payer: Priority Health Narrow/Tiered Network	$2,944.04
Rate for Payer: UHC Medicaid	$1,029.00
Rate for Payer: UHCCP Medicaid	$1,029.00

Know your out-of-pocket cost for care.

All Charges