Bronson Lakeview Hospital

All Charges

Charge

Type

Setting

Price

PR LILETTA, 52 MG

Professional

Both

$906.00

Service Code	HCPCS J7297
Min. Negotiated Rate	$453.00
Max. Negotiated Rate	$1,037.01
Rate for Payer: Aetna Commercial	$845.10
Rate for Payer: Aetna Medicare	$453.00
Rate for Payer: BCBS Complete	$1,037.01
Rate for Payer: BCBS Trust/PPO	$939.18
Rate for Payer: BCN Commercial	$941.98
Rate for Payer: Cash Price	$724.80
Rate for Payer: Cash Price	$724.80
Rate for Payer: Mclaren Medicaid	$987.63
Rate for Payer: Meridian Medicaid	$1,037.01
Rate for Payer: Opus (Opus Packaging Group) HMA	$679.50
Rate for Payer: Priority Health Choice Medicaid	$987.63
Rate for Payer: UHC Medicaid	$987.63
Rate for Payer: UHCCP Medicaid	$987.63

PR LIMITED VISUAL FIELD XM UNI/BI I&R

Professional

Both

$80.00

Service Code	HCPCS 92081
Min. Negotiated Rate	$35.34
Max. Negotiated Rate	$60.00
Rate for Payer: Aetna Commercial	$35.34
Rate for Payer: Aetna Medicare	$40.00
Rate for Payer: BCN Commercial	$49.80
Rate for Payer: Cash Price	$64.00
Rate for Payer: Cash Price	$64.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$60.00
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$42.61
Rate for Payer: Priority Health Narrow/Tiered Network	$42.61

PR LINCOMYCIN INJECTION

Professional

Both

$21.00

Service Code	HCPCS J2010
Min. Negotiated Rate	$1.95
Max. Negotiated Rate	$15.75
Rate for Payer: Aetna Commercial	$10.14
Rate for Payer: Aetna Medicare	$10.50
Rate for Payer: BCBS Trust/PPO	$1.95
Rate for Payer: BCN Commercial	$2.25
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 LITHOLAPAXY COMP/LG > 2.5 CM

Professional

Both

$964.00

Service Code	HCPCS 52318
Min. Negotiated Rate	$264.12
Max. Negotiated Rate	$760.54
Rate for Payer: Aetna Commercial	$607.33
Rate for Payer: Aetna Medicare	$482.00
Rate for Payer: BCBS Complete	$277.33
Rate for Payer: BCN Commercial	$698.17
Rate for Payer: Cash Price	$771.20
Rate for Payer: Cash Price	$771.20
Rate for Payer: Mclaren Medicaid	$264.12
Rate for Payer: Meridian Medicaid	$277.33
Rate for Payer: Opus (Opus Packaging Group) HMA	$723.00
Rate for Payer: Priority Health Choice Medicaid	$264.12
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$760.54
Rate for Payer: Priority Health Narrow/Tiered Network	$760.54
Rate for Payer: UHC Medicaid	$264.12
Rate for Payer: UHCCP Medicaid	$264.12

PR LITHOLAPAXY SMPL/SM <2.5 CM

Professional

Both

$1,708.00

Service Code	HCPCS 52317
Min. Negotiated Rate	$194.04
Max. Negotiated Rate	$1,281.00
Rate for Payer: Aetna Commercial	$444.33
Rate for Payer: Aetna Medicare	$854.00
Rate for Payer: BCBS Complete	$203.74
Rate for Payer: BCN Commercial	$511.92
Rate for Payer: Cash Price	$1,366.40
Rate for Payer: Cash Price	$1,366.40
Rate for Payer: Mclaren Medicaid	$194.04
Rate for Payer: Meridian Medicaid	$203.74
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,281.00
Rate for Payer: Priority Health Choice Medicaid	$194.04
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$557.65
Rate for Payer: Priority Health Narrow/Tiered Network	$557.65
Rate for Payer: UHC Medicaid	$194.04
Rate for Payer: UHCCP Medicaid	$194.04

PR LITHOTRIPSY XTRCORP SHOCK WAVE

Professional

Both

$1,593.00

Service Code	HCPCS 50590
Min. Negotiated Rate	$332.28
Max. Negotiated Rate	$1,194.75
Rate for Payer: Aetna Commercial	$730.18
Rate for Payer: Aetna Medicare	$796.50
Rate for Payer: BCBS Complete	$348.89
Rate for Payer: BCN Commercial	$943.70
Rate for Payer: Cash Price	$1,274.40
Rate for Payer: Cash Price	$1,274.40
Rate for Payer: Mclaren Medicaid	$332.28
Rate for Payer: Meridian Medicaid	$348.89
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,194.75
Rate for Payer: Priority Health Choice Medicaid	$332.28
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$935.75
Rate for Payer: Priority Health Narrow/Tiered Network	$935.75
Rate for Payer: UHC Medicaid	$332.28
Rate for Payer: UHCCP Medicaid	$332.28

PR LMTD LMPHADEC STAGING SPX PEL&PARA-AORTIC

Professional

Both

$4,060.00

Service Code	HCPCS 38562
Min. Negotiated Rate	$427.07
Max. Negotiated Rate	$3,045.00
Rate for Payer: Aetna Commercial	$873.15
Rate for Payer: Aetna Medicare	$2,030.00
Rate for Payer: BCBS Complete	$448.42
Rate for Payer: BCN Commercial	$1,068.17
Rate for Payer: Cash Price	$3,248.00
Rate for Payer: Cash Price	$3,248.00
Rate for Payer: Mclaren Medicaid	$427.07
Rate for Payer: Meridian Medicaid	$448.42
Rate for Payer: Opus (Opus Packaging Group) HMA	$3,045.00
Rate for Payer: Priority Health Choice Medicaid	$427.07
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$1,421.28
Rate for Payer: Priority Health Narrow/Tiered Network	$1,421.28
Rate for Payer: UHC Medicaid	$427.07
Rate for Payer: UHCCP Medicaid	$427.07

PR LMTD LMPHADEC STAGING SPX RPR AORTIC&/SPLENIC

Professional

Both

$2,916.00

Service Code	HCPCS 38564
Min. Negotiated Rate	$422.38
Max. Negotiated Rate	$2,187.00
Rate for Payer: Aetna Commercial	$878.57
Rate for Payer: Aetna Medicare	$1,458.00
Rate for Payer: BCBS Complete	$443.50
Rate for Payer: BCN Commercial	$1,058.71
Rate for Payer: Cash Price	$2,332.80
Rate for Payer: Cash Price	$2,332.80
Rate for Payer: Mclaren Medicaid	$422.38
Rate for Payer: Meridian Medicaid	$443.50
Rate for Payer: Opus (Opus Packaging Group) HMA	$2,187.00
Rate for Payer: Priority Health Choice Medicaid	$422.38
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$1,408.70
Rate for Payer: Priority Health Narrow/Tiered Network	$1,408.70
Rate for Payer: UHC Medicaid	$422.38
Rate for Payer: UHCCP Medicaid	$422.38

PR LMTD OPH XM&EVAL GENERAL ANES W/WO MNPJ GLOBE

Professional

Both

$151.00

Service Code	HCPCS 92019
Min. Negotiated Rate	$37.49
Max. Negotiated Rate	$113.25
Rate for Payer: Aetna Commercial	$77.34
Rate for Payer: Aetna Medicare	$75.50
Rate for Payer: BCBS Complete	$39.36
Rate for Payer: BCN Commercial	$78.82
Rate for Payer: Cash Price	$120.80
Rate for Payer: Cash Price	$120.80
Rate for Payer: Mclaren Medicaid	$37.49
Rate for Payer: Meridian Medicaid	$39.36
Rate for Payer: Opus (Opus Packaging Group) HMA	$113.25
Rate for Payer: Priority Health Choice Medicaid	$37.49
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$92.46
Rate for Payer: Priority Health Narrow/Tiered Network	$92.46
Rate for Payer: UHC Medicaid	$37.49
Rate for Payer: UHCCP Medicaid	$37.49

PR LNGTH/SHRT FLXR/XTNSR TDN F/ARM&/WRIST 1 EA TDN

Professional

Both

$1,669.00

Service Code	HCPCS 25280
Min. Negotiated Rate	$339.52
Max. Negotiated Rate	$1,251.75
Rate for Payer: Aetna Commercial	$754.53
Rate for Payer: Aetna Medicare	$834.50
Rate for Payer: BCBS Complete	$356.50
Rate for Payer: BCN Commercial	$870.97
Rate for Payer: Cash Price	$1,335.20
Rate for Payer: Cash Price	$1,335.20
Rate for Payer: Mclaren Medicaid	$339.52
Rate for Payer: Meridian Medicaid	$356.50
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,251.75
Rate for Payer: Priority Health Choice Medicaid	$339.52
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$931.04
Rate for Payer: Priority Health Narrow/Tiered Network	$931.04
Rate for Payer: UHC Medicaid	$339.52
Rate for Payer: UHCCP Medicaid	$339.52

PR LNGTH/SHRT TDN LEG/ANKLE MLT TDN SAME INC EA

Professional

Both

$1,403.00

Service Code	HCPCS 27686
Min. Negotiated Rate	$320.78
Max. Negotiated Rate	$1,052.25
Rate for Payer: Aetna Commercial	$714.76
Rate for Payer: Aetna Medicare	$701.50
Rate for Payer: BCBS Complete	$336.82
Rate for Payer: BCN Commercial	$808.22
Rate for Payer: Cash Price	$1,122.40
Rate for Payer: Cash Price	$1,122.40
Rate for Payer: Mclaren Medicaid	$320.78
Rate for Payer: Meridian Medicaid	$336.82
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,052.25
Rate for Payer: Priority Health Choice Medicaid	$320.78
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$863.96
Rate for Payer: Priority Health Narrow/Tiered Network	$863.96
Rate for Payer: UHC Medicaid	$320.78
Rate for Payer: UHCCP Medicaid	$320.78

PR LNGTH/SHRT TENDON LEG/ANKLE 1 TENDON SPX

Professional

Both

$1,876.00

Service Code	HCPCS 27685
Min. Negotiated Rate	$282.86
Max. Negotiated Rate	$1,407.00
Rate for Payer: Aetna Commercial	$616.27
Rate for Payer: Aetna Medicare	$938.00
Rate for Payer: BCBS Complete	$297.00
Rate for Payer: BCN Commercial	$710.12
Rate for Payer: Cash Price	$1,500.80
Rate for Payer: Cash Price	$1,500.80
Rate for Payer: Mclaren Medicaid	$282.86
Rate for Payer: Meridian Medicaid	$297.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,407.00
Rate for Payer: Priority Health Choice Medicaid	$282.86
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$759.10
Rate for Payer: Priority Health Narrow/Tiered Network	$759.10
Rate for Payer: UHC Medicaid	$282.86
Rate for Payer: UHCCP Medicaid	$282.86

PR LOCM 250-299MG/ML IODINE,1ML

Professional

Both

$5.00

Service Code	HCPCS Q9948
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$3.75
Rate for Payer: Aetna Medicare	$2.50
Rate for Payer: BCBS Complete	$2.00
Rate for Payer: Cash Price	$4.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$3.75

PR LORAZEPAM INJECTION

Professional

Both

$7.00

Service Code	HCPCS J2060
Min. Negotiated Rate	$0.47
Max. Negotiated Rate	$5.25
Rate for Payer: Aetna Commercial	$1.16
Rate for Payer: Aetna Medicare	$3.50
Rate for Payer: BCBS Trust/PPO	$0.47
Rate for Payer: BCN Commercial	$0.52
Rate for Payer: Cash Price	$5.60
Rate for Payer: Cash Price	$5.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$5.25

PR LOWER LID BLEPHAROPLASTY

Professional

Both

$2,704.00

Hospital Revenue Code	990
Min. Negotiated Rate	$1,081.60
Max. Negotiated Rate	$2,028.00
Rate for Payer: Aetna Medicare	$1,352.00
Rate for Payer: BCBS Complete	$1,081.60
Rate for Payer: Cash Price	$2,163.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$2,028.00

PR LOW INTENSITY US STIMJ BONE HEALING NONINVASIVE

Professional

Both

$107.00

Service Code	HCPCS 20979
Min. Negotiated Rate	$42.80
Max. Negotiated Rate	$80.25
Rate for Payer: Aetna Commercial	$42.80
Rate for Payer: Aetna Medicare	$53.50
Rate for Payer: BCBS Complete	$42.80
Rate for Payer: BCN Commercial	$46.31
Rate for Payer: Cash Price	$85.60
Rate for Payer: Cash Price	$85.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$80.25
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$49.50
Rate for Payer: Priority Health Narrow/Tiered Network	$49.50

PR LT COMPRES BAND >=3"" <5""/YD

Professional

Both

$3.00

Service Code	HCPCS A6449
Min. Negotiated Rate	$1.20
Max. Negotiated Rate	$2.39
Rate for Payer: Aetna Commercial	$1.63
Rate for Payer: Aetna Medicare	$1.50
Rate for Payer: BCBS Complete	$1.20
Rate for Payer: BCN Commercial	$2.39
Rate for Payer: Cash Price	$2.40
Rate for Payer: Cash Price	$2.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$2.25

PR LT COMPRES BAND <3""/YD

Professional

Both

$3.00

Service Code	HCPCS A6448
Min. Negotiated Rate	$1.07
Max. Negotiated Rate	$2.25
Rate for Payer: Aetna Commercial	$1.07
Rate for Payer: Aetna Medicare	$1.50
Rate for Payer: BCBS Complete	$1.20
Rate for Payer: BCN Commercial	$1.57
Rate for Payer: Cash Price	$2.40
Rate for Payer: Cash Price	$2.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$2.25

PR LT COMPRES BAND >=5""/YD

Professional

Both

$5.00

Service Code	HCPCS A6450
Min. Negotiated Rate	$1.63
Max. Negotiated Rate	$3.75
Rate for Payer: Aetna Commercial	$1.63
Rate for Payer: Aetna Medicare	$2.50
Rate for Payer: BCBS Complete	$2.00
Rate for Payer: BCN Commercial	$2.39
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 LUX IR ABD/BACK

Professional

Both

$263.00

Hospital Revenue Code	990
Min. Negotiated Rate	$105.20
Max. Negotiated Rate	$197.25
Rate for Payer: Aetna Medicare	$131.50
Rate for Payer: BCBS Complete	$105.20
Rate for Payer: Cash Price	$210.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$197.25

PR LUX IR ARMS

Professional

Both

$132.00

Hospital Revenue Code	990
Min. Negotiated Rate	$52.80
Max. Negotiated Rate	$99.00
Rate for Payer: Aetna Medicare	$66.00
Rate for Payer: BCBS Complete	$52.80
Rate for Payer: Cash Price	$105.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$99.00

PR LUX IR BUTTOCKS

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 LUX IR CHEST

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 LUX IR FACE & NECK

Professional

Both

$263.00

Hospital Revenue Code	990
Min. Negotiated Rate	$105.20
Max. Negotiated Rate	$197.25
Rate for Payer: Aetna Medicare	$131.50
Rate for Payer: BCBS Complete	$105.20
Rate for Payer: Cash Price	$210.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$197.25

PR LUX IR UP LEGS

Professional

Both

$263.00

Hospital Revenue Code	990
Min. Negotiated Rate	$105.20
Max. Negotiated Rate	$197.25
Rate for Payer: Aetna Medicare	$131.50
Rate for Payer: BCBS Complete	$105.20
Rate for Payer: Cash Price	$210.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$197.25

Know your out-of-pocket cost for care.

All Charges