Bronson Lakeview Hospital

All Charges

Charge

Type

Setting

Price

PR MEDICATION THERAPY EACH ADDITIONAL 15 MIN

Professional

Both

$13.00

Service Code	HCPCS 99607
Min. Negotiated Rate	$5.20
Max. Negotiated Rate	$45.29
Rate for Payer: Aetna Commercial	$45.29
Rate for Payer: Aetna Medicare	$6.50
Rate for Payer: BCBS Complete	$5.20
Rate for Payer: Cash Price	$10.40
Rate for Payer: Cash Price	$10.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$9.75

PR MEDICATION THERAPY INITIAL 15 MIN ESTABLISHED PT

Professional

Both

$33.00

Service Code	HCPCS 99606
Min. Negotiated Rate	$13.20
Max. Negotiated Rate	$33.89
Rate for Payer: Aetna Commercial	$33.89
Rate for Payer: Aetna Medicare	$16.50
Rate for Payer: BCBS Complete	$13.20
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 MEDICATION THERAPY INITIAL 15 MIN NEW PATIENT

Professional

Both

$66.00

Service Code	HCPCS 99605
Min. Negotiated Rate	$26.40
Max. Negotiated Rate	$67.55
Rate for Payer: Aetna Commercial	$67.55
Rate for Payer: Aetna Medicare	$33.00
Rate for Payer: BCBS Complete	$26.40
Rate for Payer: Cash Price	$52.80
Rate for Payer: Cash Price	$52.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$49.50

PR MEDROXYPROGESTERONE ACETATE

Professional

Both

$1.00

Service Code	HCPCS J1050
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.75
Rate for Payer: Aetna Commercial	$0.52
Rate for Payer: Aetna Medicare	$0.50
Rate for Payer: BCBS Trust/PPO	$0.01
Rate for Payer: BCN Commercial	$0.01
Rate for Payer: Cash Price	$0.80
Rate for Payer: Cash Price	$0.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$0.75

PR MEDROXYPROGESTERONE INJ

Professional

Both

$32.00

Service Code	HCPCS J1051
Min. Negotiated Rate	$12.80
Max. Negotiated Rate	$24.00
Rate for Payer: Aetna Medicare	$16.00
Rate for Payer: BCBS Complete	$12.80
Rate for Payer: Cash Price	$25.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$24.00

PR MEDRXYPROGESTER ACETATE INJ

Professional

Both

$84.00

Service Code	HCPCS J1055
Min. Negotiated Rate	$33.60
Max. Negotiated Rate	$63.00
Rate for Payer: Aetna Medicare	$42.00
Rate for Payer: BCBS Complete	$33.60
Rate for Payer: Cash Price	$67.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$63.00

PR MENACWYD/MENACWY-CRM CONJ VACC GRPS ACWY IM USE

Professional

Both

$147.00

Service Code	HCPCS 90734
Min. Negotiated Rate	$73.50
Max. Negotiated Rate	$166.75
Rate for Payer: Aetna Commercial	$151.33
Rate for Payer: Aetna Medicare	$73.50
Rate for Payer: BCBS Trust/PPO	$166.75
Rate for Payer: BCN Commercial	$163.95
Rate for Payer: Cash Price	$117.60
Rate for Payer: Cash Price	$117.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$110.25

PR MENACWY-TT CONJ VACC SEROGROUPS ACWY FOR IM USE

Professional

Both

$190.00

Service Code	HCPCS 90619
Min. Negotiated Rate	$95.00
Max. Negotiated Rate	$177.11
Rate for Payer: Aetna Commercial	$159.10
Rate for Payer: Aetna Medicare	$95.00
Rate for Payer: BCBS Trust/PPO	$177.11
Rate for Payer: BCN Commercial	$169.10
Rate for Payer: Cash Price	$152.00
Rate for Payer: Cash Price	$152.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$142.50

PR MENB-4C RECOMBNT PRTN & OUTER MEMB VESIC VACC IM

Professional

Both

$271.00

Service Code	HCPCS 90620
Min. Negotiated Rate	$135.50
Max. Negotiated Rate	$237.13
Rate for Payer: Aetna Commercial	$215.42
Rate for Payer: Aetna Medicare	$135.50
Rate for Payer: BCBS Trust/PPO	$237.13
Rate for Payer: BCN Commercial	$233.20
Rate for Payer: Cash Price	$216.80
Rate for Payer: Cash Price	$216.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$203.25

PR MENB-FHBP RECOMBNT LIPOPROTEIN VACC 2/3 DOSE IM

Professional

Both

$190.00

Service Code	HCPCS 90621
Min. Negotiated Rate	$95.00
Max. Negotiated Rate	$225.91
Rate for Payer: Aetna Commercial	$183.17
Rate for Payer: Aetna Medicare	$95.00
Rate for Payer: BCBS Trust/PPO	$225.91
Rate for Payer: BCN Commercial	$203.87
Rate for Payer: Cash Price	$152.00
Rate for Payer: Cash Price	$152.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$142.50

PR MEPERIDINE HYDROCHL /100 MG

Professional

Both

$10.00

Service Code	HCPCS J2175
Min. Negotiated Rate	$2.20
Max. Negotiated Rate	$7.52
Rate for Payer: Aetna Commercial	$7.52
Rate for Payer: Aetna Medicare	$5.00
Rate for Payer: BCBS Trust/PPO	$2.20
Rate for Payer: BCN Commercial	$2.57
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 MEPERIDINE/PROMETHAZINE INJ

Professional

Both

$11.00

Service Code	HCPCS J2180
Min. Negotiated Rate	$5.50
Max. Negotiated Rate	$8.25
Rate for Payer: Aetna Commercial	$7.58
Rate for Payer: Aetna Medicare	$5.50
Rate for Payer: Cash Price	$8.80
Rate for Payer: Cash Price	$8.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$8.25

PR METATARSECTOMY

Professional

Both

$1,103.00

Service Code	HCPCS 28140
Min. Negotiated Rate	$252.62
Max. Negotiated Rate	$827.25
Rate for Payer: Aetna Commercial	$575.34
Rate for Payer: Aetna Medicare	$551.50
Rate for Payer: BCBS Complete	$265.25
Rate for Payer: BCN Commercial	$641.40
Rate for Payer: Cash Price	$882.40
Rate for Payer: Cash Price	$882.40
Rate for Payer: Mclaren Medicaid	$252.62
Rate for Payer: Meridian Medicaid	$265.25
Rate for Payer: Opus (Opus Packaging Group) HMA	$827.25
Rate for Payer: Priority Health Choice Medicaid	$252.62
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$685.63
Rate for Payer: Priority Health Narrow/Tiered Network	$685.63
Rate for Payer: UHC Medicaid	$252.62
Rate for Payer: UHCCP Medicaid	$252.62

PR METHYLPREDNISOLONE 20 MG INJ

Professional

Both

$10.00

Service Code	HCPCS J1020
Min. Negotiated Rate	$1.79
Max. Negotiated Rate	$7.50
Rate for Payer: Aetna Commercial	$7.25
Rate for Payer: Aetna Medicare	$5.00
Rate for Payer: BCBS Complete	$4.00
Rate for Payer: BCN Commercial	$1.79
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 METHYLPREDNISOLONE 40 MG INJ

Professional

Both

$15.00

Service Code	HCPCS J1030
Min. Negotiated Rate	$3.27
Max. Negotiated Rate	$11.25
Rate for Payer: Aetna Commercial	$6.61
Rate for Payer: Aetna Medicare	$7.50
Rate for Payer: BCBS Complete	$6.00
Rate for Payer: BCN Commercial	$3.27
Rate for Payer: Cash Price	$12.00
Rate for Payer: Cash Price	$12.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$11.25

PR METHYLPREDNISOLONE 80 MG INJ

Professional

Both

$27.00

Service Code	HCPCS J1040
Min. Negotiated Rate	$5.37
Max. Negotiated Rate	$20.25
Rate for Payer: Aetna Commercial	$10.10
Rate for Payer: Aetna Medicare	$13.50
Rate for Payer: BCBS Complete	$10.80
Rate for Payer: BCN Commercial	$5.37
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 METHYLPREDNISOLONE INJECTION

Professional

Both

$10.00

Service Code	HCPCS J2920
Min. Negotiated Rate	$3.17
Max. Negotiated Rate	$7.50
Rate for Payer: Aetna Commercial	$4.31
Rate for Payer: Aetna Medicare	$5.00
Rate for Payer: BCBS Complete	$4.00
Rate for Payer: BCN Commercial	$3.17
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 METHYLPREDNISOLONE INJECTION

Professional

Both

$27.00

Service Code	HCPCS J2930
Min. Negotiated Rate	$3.00
Max. Negotiated Rate	$20.25
Rate for Payer: Aetna Commercial	$6.06
Rate for Payer: Aetna Medicare	$13.50
Rate for Payer: BCBS Complete	$10.80
Rate for Payer: BCN Commercial	$3.00
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 MGMT LVR HEMRRG CPLX SUTR WND/INJ

Professional

Both

$3,558.00

Service Code	HCPCS 47360
Min. Negotiated Rate	$1,112.71
Max. Negotiated Rate	$3,419.09
Rate for Payer: Aetna Commercial	$2,542.61
Rate for Payer: Aetna Medicare	$1,779.00
Rate for Payer: BCBS Complete	$1,168.35
Rate for Payer: BCN Commercial	$2,806.12
Rate for Payer: Cash Price	$2,846.40
Rate for Payer: Cash Price	$2,846.40
Rate for Payer: Mclaren Medicaid	$1,112.71
Rate for Payer: Meridian Medicaid	$1,168.35
Rate for Payer: Opus (Opus Packaging Group) HMA	$2,668.50
Rate for Payer: Priority Health Choice Medicaid	$1,112.71
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$3,419.09
Rate for Payer: Priority Health Narrow/Tiered Network	$3,419.09
Rate for Payer: UHC Medicaid	$1,112.71
Rate for Payer: UHCCP Medicaid	$1,112.71

PR MGMT LVR HEMRRG EXPL WND DBRDMT COAGJ/SUTR

Professional

Both

$6,566.00

Service Code	HCPCS 47361
Min. Negotiated Rate	$1,766.20
Max. Negotiated Rate	$5,474.76
Rate for Payer: Aetna Commercial	$4,086.75
Rate for Payer: Aetna Medicare	$3,283.00
Rate for Payer: BCBS Complete	$1,854.51
Rate for Payer: BCN Commercial	$4,493.28
Rate for Payer: Cash Price	$5,252.80
Rate for Payer: Cash Price	$5,252.80
Rate for Payer: Mclaren Medicaid	$1,766.20
Rate for Payer: Meridian Medicaid	$1,854.51
Rate for Payer: Opus (Opus Packaging Group) HMA	$4,924.50
Rate for Payer: Priority Health Choice Medicaid	$1,766.20
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$5,474.76
Rate for Payer: Priority Health Narrow/Tiered Network	$5,474.76
Rate for Payer: UHC Medicaid	$1,766.20
Rate for Payer: UHCCP Medicaid	$1,766.20

PR MGMT LVR HEMRRG RE-EXPL WND RMVL PACKING

Professional

Both

$3,089.00

Service Code	HCPCS 47362
Min. Negotiated Rate	$853.28
Max. Negotiated Rate	$2,593.28
Rate for Payer: Aetna Commercial	$1,928.21
Rate for Payer: Aetna Medicare	$1,544.50
Rate for Payer: BCBS Complete	$895.94
Rate for Payer: BCN Commercial	$2,128.37
Rate for Payer: Cash Price	$2,471.20
Rate for Payer: Cash Price	$2,471.20
Rate for Payer: Mclaren Medicaid	$853.28
Rate for Payer: Meridian Medicaid	$895.94
Rate for Payer: Opus (Opus Packaging Group) HMA	$2,316.75
Rate for Payer: Priority Health Choice Medicaid	$853.28
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$2,593.28
Rate for Payer: Priority Health Narrow/Tiered Network	$2,593.28
Rate for Payer: UHC Medicaid	$853.28
Rate for Payer: UHCCP Medicaid	$853.28

PR MGMT LVR HEMRRG SMPL SUTR LVR WND/INJ

Professional

Both

$2,990.00

Service Code	HCPCS 47350
Min. Negotiated Rate	$819.84
Max. Negotiated Rate	$2,488.31
Rate for Payer: Aetna Commercial	$1,849.58
Rate for Payer: Aetna Medicare	$1,495.00
Rate for Payer: BCBS Complete	$860.83
Rate for Payer: BCN Commercial	$2,042.22
Rate for Payer: Cash Price	$2,392.00
Rate for Payer: Cash Price	$2,392.00
Rate for Payer: Mclaren Medicaid	$819.84
Rate for Payer: Meridian Medicaid	$860.83
Rate for Payer: Opus (Opus Packaging Group) HMA	$2,242.50
Rate for Payer: Priority Health Choice Medicaid	$819.84
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$2,488.31
Rate for Payer: Priority Health Narrow/Tiered Network	$2,488.31
Rate for Payer: UHC Medicaid	$819.84
Rate for Payer: UHCCP Medicaid	$819.84

PR MH PARTIAL HOSP TX UNDER 24H

Professional

Both

$267.00

Service Code	HCPCS H0035
Min. Negotiated Rate	$106.80
Max. Negotiated Rate	$268.86
Rate for Payer: Aetna Commercial	$268.86
Rate for Payer: Aetna Medicare	$133.50
Rate for Payer: BCBS Complete	$106.80
Rate for Payer: Cash Price	$213.60
Rate for Payer: Cash Price	$213.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$200.25

PR MICRONEEDLING PIN ADB/THIGHS/BACK

Professional

Both

$473.00

Hospital Revenue Code	990
Min. Negotiated Rate	$189.20
Max. Negotiated Rate	$354.75
Rate for Payer: Aetna Medicare	$236.50
Rate for Payer: BCBS Complete	$189.20
Rate for Payer: Cash Price	$378.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$354.75

PR MICRONEEDLING PIN FULL 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

Know your out-of-pocket cost for care.

All Charges