Bronson Lakeview Hospital

All Charges

Charge

Type

Setting

Price

PR MOD SED OTHER PHYS/QHP INITIAL 15 MINS 5/> YRS

Professional

Both

$160.00

Service Code	HCPCS 99156
Min. Negotiated Rate	$45.37
Max. Negotiated Rate	$209.06
Rate for Payer: Aetna Commercial	$85.20
Rate for Payer: Aetna Medicare	$80.00
Rate for Payer: BCBS Complete	$47.64
Rate for Payer: BCN Commercial	$120.35
Rate for Payer: Cash Price	$128.00
Rate for Payer: Cash Price	$128.00
Rate for Payer: Mclaren Medicaid	$45.37
Rate for Payer: Meridian Medicaid	$47.64
Rate for Payer: Opus (Opus Packaging Group) HMA	$120.00
Rate for Payer: Priority Health Choice Medicaid	$45.37
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$209.06
Rate for Payer: Priority Health Narrow/Tiered Network	$209.06
Rate for Payer: UHC Medicaid	$45.37
Rate for Payer: UHCCP Medicaid	$45.37

PR MOD SED SAME PHYS/QHP EACH ADDL 15 MINS

Professional

Both

$34.00

Service Code	HCPCS 99153
Min. Negotiated Rate	$11.06
Max. Negotiated Rate	$25.50
Rate for Payer: Aetna Commercial	$11.06
Rate for Payer: Aetna Medicare	$17.00
Rate for Payer: BCN Commercial	$19.69
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	$19.20
Rate for Payer: Priority Health Narrow/Tiered Network	$19.20

PR MOD SED SAME PHYS/QHP INITIAL 15 MINS <5 YRS

Professional

Both

$168.00

Service Code	HCPCS 99151
Min. Negotiated Rate	$13.42
Max. Negotiated Rate	$126.00
Rate for Payer: Aetna Commercial	$27.86
Rate for Payer: Aetna Medicare	$84.00
Rate for Payer: BCBS Complete	$14.09
Rate for Payer: BCN Commercial	$38.84
Rate for Payer: Cash Price	$134.40
Rate for Payer: Cash Price	$134.40
Rate for Payer: Mclaren Medicaid	$13.42
Rate for Payer: Meridian Medicaid	$14.09
Rate for Payer: Opus (Opus Packaging Group) HMA	$126.00
Rate for Payer: Priority Health Choice Medicaid	$13.42
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$67.48
Rate for Payer: Priority Health Narrow/Tiered Network	$67.48
Rate for Payer: UHC Medicaid	$13.42
Rate for Payer: UHCCP Medicaid	$13.42

PR MOD SED SAME PHYS/QHP INITIAL 15 MINS 5/> YRS

Professional

Both

$160.00

Service Code	HCPCS 99152
Min. Negotiated Rate	$7.03
Max. Negotiated Rate	$120.00
Rate for Payer: Aetna Commercial	$13.74
Rate for Payer: Aetna Medicare	$80.00
Rate for Payer: BCBS Complete	$7.38
Rate for Payer: BCN Commercial	$19.69
Rate for Payer: Cash Price	$128.00
Rate for Payer: Cash Price	$128.00
Rate for Payer: Mclaren Medicaid	$7.03
Rate for Payer: Meridian Medicaid	$7.38
Rate for Payer: Opus (Opus Packaging Group) HMA	$120.00
Rate for Payer: Priority Health Choice Medicaid	$7.03
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$39.51
Rate for Payer: Priority Health Narrow/Tiered Network	$39.51
Rate for Payer: UHC Medicaid	$7.03
Rate for Payer: UHCCP Medicaid	$7.03

PR MONALISA TOUCH, SERIES, UP TO 7 VISITS, LICHEN SCLEROSUS

Professional

Both

$2,206.00

Hospital Revenue Code	990
Min. Negotiated Rate	$882.40
Max. Negotiated Rate	$1,654.50
Rate for Payer: Aetna Medicare	$1,103.00
Rate for Payer: BCBS Complete	$882.40
Rate for Payer: Cash Price	$1,764.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,654.50

PR MONOVISC INJ PER DOSE

Professional

Both

$969.00

Service Code	HCPCS J7327
Min. Negotiated Rate	$484.50
Max. Negotiated Rate	$800.00
Rate for Payer: Aetna Commercial	$735.80
Rate for Payer: Aetna Medicare	$484.50
Rate for Payer: BCBS Trust/PPO	$575.42
Rate for Payer: BCN Commercial	$800.00
Rate for Payer: Cash Price	$775.20
Rate for Payer: Cash Price	$775.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$726.75

PR MORPHINE SULFATE INJECTION

Professional

Both

$8.00

Service Code	HCPCS J2270
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$6.00
Rate for Payer: Aetna Commercial	$4.80
Rate for Payer: Aetna Medicare	$4.00
Rate for Payer: BCBS Trust/PPO	$0.06
Rate for Payer: BCN Commercial	$0.06
Rate for Payer: Cash Price	$6.40
Rate for Payer: Cash Price	$6.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$6.00

PR MOTOR &/SENS NRV CNDJ PRECONF ELTRD ARRAY LIMB

Professional

Both

$142.00

Service Code	HCPCS 95905
Min. Negotiated Rate	$45.01
Max. Negotiated Rate	$106.50
Rate for Payer: Aetna Commercial	$49.71
Rate for Payer: Aetna Medicare	$71.00
Rate for Payer: BCN Commercial	$48.80
Rate for Payer: Cash Price	$113.60
Rate for Payer: Cash Price	$113.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$106.50
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$45.01
Rate for Payer: Priority Health Narrow/Tiered Network	$45.01

PR MPSV4 VACCINE GROUPS ACYW-135 SUBQ USE

Professional

Both

$133.00

Service Code	HCPCS 90733
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$125.50
Rate for Payer: Aetna Commercial	$125.50
Rate for Payer: Aetna Medicare	$66.50
Rate for Payer: BCBS Complete	$53.20
Rate for Payer: BCBS Trust/PPO	$125.49
Rate for Payer: BCN Commercial	$0.01
Rate for Payer: Cash Price	$106.40
Rate for Payer: Cash Price	$106.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$99.75

PR MULTIPLE FAM GROUP BHV TX GDN PHYS/QHP EA 15 MIN

Professional

Both

$63.00

Service Code	HCPCS 97157
Min. Negotiated Rate	$20.79
Max. Negotiated Rate	$47.25
Rate for Payer: Aetna Commercial	$20.79
Rate for Payer: Aetna Medicare	$31.50
Rate for Payer: BCBS Complete	$25.20
Rate for Payer: BCN Commercial	$23.79
Rate for Payer: Cash Price	$50.40
Rate for Payer: Cash Price	$50.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$47.25
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$45.93
Rate for Payer: Priority Health Narrow/Tiered Network	$45.93

PR MULTIPLE FAMILY GROUP PSYCHOTHERAPY

Professional

Both

$95.00

Service Code	HCPCS 90849
Min. Negotiated Rate	$38.00
Max. Negotiated Rate	$71.25
Rate for Payer: Aetna Commercial	$46.80
Rate for Payer: Aetna Medicare	$47.50
Rate for Payer: BCBS Complete	$38.00
Rate for Payer: BCN Commercial	$45.32
Rate for Payer: Cash Price	$76.00
Rate for Payer: Cash Price	$76.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$71.25
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$38.81
Rate for Payer: Priority Health Narrow/Tiered Network	$38.81

PR MUSCLE-SKIN FLAP,HEAD/NECK

Professional

Both

$3,344.00

Service Code	HCPCS 15732
Min. Negotiated Rate	$1,337.60
Max. Negotiated Rate	$2,508.00
Rate for Payer: Aetna Medicare	$1,672.00
Rate for Payer: BCBS Complete	$1,337.60
Rate for Payer: Cash Price	$2,675.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$2,508.00

PR MUSCLE/TENDON TRANSFER UPPER ARM/ELBOW SINGLE

Professional

Both

$1,174.00

Service Code	HCPCS 24301
Min. Negotiated Rate	$446.87
Max. Negotiated Rate	$1,224.88
Rate for Payer: Aetna Commercial	$1,002.27
Rate for Payer: Aetna Medicare	$587.00
Rate for Payer: BCBS Complete	$469.21
Rate for Payer: BCN Commercial	$1,145.85
Rate for Payer: Cash Price	$939.20
Rate for Payer: Cash Price	$939.20
Rate for Payer: Mclaren Medicaid	$446.87
Rate for Payer: Meridian Medicaid	$469.21
Rate for Payer: Opus (Opus Packaging Group) HMA	$880.50
Rate for Payer: Priority Health Choice Medicaid	$446.87
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$1,224.88
Rate for Payer: Priority Health Narrow/Tiered Network	$1,224.88
Rate for Payer: UHC Medicaid	$446.87
Rate for Payer: UHCCP Medicaid	$446.87

PR MUSCLE TRANSFER SHOULDER/UPPER ARM MULTIPLE

Professional

Both

$3,157.00

Service Code	HCPCS 23397
Min. Negotiated Rate	$664.99
Max. Negotiated Rate	$2,367.75
Rate for Payer: Aetna Commercial	$1,512.60
Rate for Payer: Aetna Medicare	$1,578.50
Rate for Payer: BCBS Complete	$698.24
Rate for Payer: BCN Commercial	$1,722.51
Rate for Payer: Cash Price	$2,525.60
Rate for Payer: Cash Price	$2,525.60
Rate for Payer: Mclaren Medicaid	$664.99
Rate for Payer: Meridian Medicaid	$698.24
Rate for Payer: Opus (Opus Packaging Group) HMA	$2,367.75
Rate for Payer: Priority Health Choice Medicaid	$664.99
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$1,841.33
Rate for Payer: Priority Health Narrow/Tiered Network	$1,841.33
Rate for Payer: UHC Medicaid	$664.99
Rate for Payer: UHCCP Medicaid	$664.99

PR MUSCLE TRANSFER SHOULDER/UPPER ARM SINGLE

Professional

Both

$3,516.00

Service Code	HCPCS 23395
Min. Negotiated Rate	$751.04
Max. Negotiated Rate	$2,637.00
Rate for Payer: Aetna Commercial	$1,710.89
Rate for Payer: Aetna Medicare	$1,758.00
Rate for Payer: BCBS Complete	$788.59
Rate for Payer: BCN Commercial	$1,946.11
Rate for Payer: Cash Price	$2,812.80
Rate for Payer: Cash Price	$2,812.80
Rate for Payer: Mclaren Medicaid	$751.04
Rate for Payer: Meridian Medicaid	$788.59
Rate for Payer: Opus (Opus Packaging Group) HMA	$2,637.00
Rate for Payer: Priority Health Choice Medicaid	$751.04
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$2,080.33
Rate for Payer: Priority Health Narrow/Tiered Network	$2,080.33
Rate for Payer: UHC Medicaid	$751.04
Rate for Payer: UHCCP Medicaid	$751.04

PR MUSC MYOCUTANEOUS/FASCIOCUTANEOUS FLAP LXTR

Professional

Both

$2,549.00

Service Code	HCPCS 15738
Min. Negotiated Rate	$732.29
Max. Negotiated Rate	$1,911.75
Rate for Payer: Aetna Commercial	$1,391.76
Rate for Payer: Aetna Medicare	$1,274.50
Rate for Payer: BCBS Complete	$768.90
Rate for Payer: BCN Commercial	$1,898.30
Rate for Payer: Cash Price	$2,039.20
Rate for Payer: Cash Price	$2,039.20
Rate for Payer: Mclaren Medicaid	$732.29
Rate for Payer: Meridian Medicaid	$768.90
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,911.75
Rate for Payer: Priority Health Choice Medicaid	$732.29
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$1,737.44
Rate for Payer: Priority Health Narrow/Tiered Network	$1,737.44
Rate for Payer: UHC Medicaid	$732.29
Rate for Payer: UHCCP Medicaid	$732.29

PR MUSC MYOCUTANEOUS/FASCIOCUTANEOUS FLAP TRUNK

Professional

Both

$4,738.00

Service Code	HCPCS 15734
Min. Negotiated Rate	$884.38
Max. Negotiated Rate	$3,553.50
Rate for Payer: Aetna Commercial	$1,635.70
Rate for Payer: Aetna Medicare	$2,369.00
Rate for Payer: BCBS Complete	$928.60
Rate for Payer: BCN Commercial	$2,257.35
Rate for Payer: Cash Price	$3,790.40
Rate for Payer: Cash Price	$3,790.40
Rate for Payer: Mclaren Medicaid	$884.38
Rate for Payer: Meridian Medicaid	$928.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$3,553.50
Rate for Payer: Priority Health Choice Medicaid	$884.38
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$2,066.06
Rate for Payer: Priority Health Narrow/Tiered Network	$2,066.06
Rate for Payer: UHC Medicaid	$884.38
Rate for Payer: UHCCP Medicaid	$884.38

PR MUSC MYOCUTANEOUS/FASCIOCUTANEOUS FLAP UXTR

Professional

Both

$2,375.00

Service Code	HCPCS 15736
Min. Negotiated Rate	$708.65
Max. Negotiated Rate	$1,831.57
Rate for Payer: Aetna Commercial	$1,317.66
Rate for Payer: Aetna Medicare	$1,187.50
Rate for Payer: BCBS Complete	$744.08
Rate for Payer: BCN Commercial	$1,831.57
Rate for Payer: Cash Price	$1,900.00
Rate for Payer: Cash Price	$1,900.00
Rate for Payer: Mclaren Medicaid	$708.65
Rate for Payer: Meridian Medicaid	$744.08
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,781.25
Rate for Payer: Priority Health Choice Medicaid	$708.65
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$1,676.36
Rate for Payer: Priority Health Narrow/Tiered Network	$1,676.36
Rate for Payer: UHC Medicaid	$708.65
Rate for Payer: UHCCP Medicaid	$708.65

PR MUSC MYOQ/FSCQ FLAP HEAD&NECK W/NAMED VASC PEDCL

Professional

Both

$3,257.00

Service Code	HCPCS 15733
Min. Negotiated Rate	$579.15
Max. Negotiated Rate	$2,442.75
Rate for Payer: Aetna Commercial	$1,117.11
Rate for Payer: Aetna Medicare	$1,628.50
Rate for Payer: BCBS Complete	$608.11
Rate for Payer: BCN Commercial	$1,545.24
Rate for Payer: Cash Price	$2,605.60
Rate for Payer: Cash Price	$2,605.60
Rate for Payer: Mclaren Medicaid	$579.15
Rate for Payer: Meridian Medicaid	$608.11
Rate for Payer: Opus (Opus Packaging Group) HMA	$2,442.75
Rate for Payer: Priority Health Choice Medicaid	$579.15
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$1,414.29
Rate for Payer: Priority Health Narrow/Tiered Network	$1,414.29
Rate for Payer: UHC Medicaid	$579.15
Rate for Payer: UHCCP Medicaid	$579.15

PR MYOCARDIAL RESECTION

Professional

Both

$6,456.00

Service Code	HCPCS 33542
Min. Negotiated Rate	$1,565.98
Max. Negotiated Rate	$4,842.00
Rate for Payer: Aetna Commercial	$3,532.04
Rate for Payer: Aetna Medicare	$3,228.00
Rate for Payer: BCBS Complete	$1,644.28
Rate for Payer: BCN Commercial	$3,862.34
Rate for Payer: Cash Price	$5,164.80
Rate for Payer: Cash Price	$5,164.80
Rate for Payer: Mclaren Medicaid	$1,565.98
Rate for Payer: Meridian Medicaid	$1,644.28
Rate for Payer: Opus (Opus Packaging Group) HMA	$4,842.00
Rate for Payer: Priority Health Choice Medicaid	$1,565.98
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$4,153.45
Rate for Payer: Priority Health Narrow/Tiered Network	$4,153.45
Rate for Payer: UHC Medicaid	$1,565.98
Rate for Payer: UHCCP Medicaid	$1,565.98

PR MYOMECTOMY 1-4 MYOMAS 250 GM/< VAGINAL APPR

Professional

Both

$2,020.00

Service Code	HCPCS 58145
Min. Negotiated Rate	$318.22
Max. Negotiated Rate	$1,515.00
Rate for Payer: Aetna Commercial	$676.97
Rate for Payer: Aetna Medicare	$1,010.00
Rate for Payer: BCBS Complete	$334.13
Rate for Payer: BCN Commercial	$844.08
Rate for Payer: Cash Price	$1,616.00
Rate for Payer: Cash Price	$1,616.00
Rate for Payer: Mclaren Medicaid	$318.22
Rate for Payer: Meridian Medicaid	$334.13
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,515.00
Rate for Payer: Priority Health Choice Medicaid	$318.22
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$854.86
Rate for Payer: Priority Health Narrow/Tiered Network	$854.86
Rate for Payer: UHC Medicaid	$318.22
Rate for Payer: UHCCP Medicaid	$318.22

PR MYOMECTOMY 1-4 MYOMAS W/250 GM/< ABDOMINAL APPR

Professional

Both

$3,124.00

Service Code	HCPCS 58140
Min. Negotiated Rate	$518.44
Max. Negotiated Rate	$2,343.00
Rate for Payer: Aetna Commercial	$1,116.00
Rate for Payer: Aetna Medicare	$1,562.00
Rate for Payer: BCBS Complete	$544.36
Rate for Payer: BCN Commercial	$1,379.90
Rate for Payer: Cash Price	$2,499.20
Rate for Payer: Cash Price	$2,499.20
Rate for Payer: Mclaren Medicaid	$518.44
Rate for Payer: Meridian Medicaid	$544.36
Rate for Payer: Opus (Opus Packaging Group) HMA	$2,343.00
Rate for Payer: Priority Health Choice Medicaid	$518.44
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$1,397.54
Rate for Payer: Priority Health Narrow/Tiered Network	$1,397.54
Rate for Payer: UHC Medicaid	$518.44
Rate for Payer: UHCCP Medicaid	$518.44

PR MYOMECTOMY 5/> MYOMAS &/>250 GM ABDOMINA

Professional

Both

$2,281.00

Service Code	HCPCS 58146
Min. Negotiated Rate	$647.09
Max. Negotiated Rate	$1,749.58
Rate for Payer: Aetna Commercial	$1,387.27
Rate for Payer: Aetna Medicare	$1,140.50
Rate for Payer: BCBS Complete	$679.44
Rate for Payer: BCN Commercial	$1,727.50
Rate for Payer: Cash Price	$1,824.80
Rate for Payer: Cash Price	$1,824.80
Rate for Payer: Mclaren Medicaid	$647.09
Rate for Payer: Meridian Medicaid	$679.44
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,710.75
Rate for Payer: Priority Health Choice Medicaid	$647.09
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$1,749.58
Rate for Payer: Priority Health Narrow/Tiered Network	$1,749.58
Rate for Payer: UHC Medicaid	$647.09
Rate for Payer: UHCCP Medicaid	$647.09

PR MYRINGOPLASTY

Professional

Both

$1,202.00

Service Code	HCPCS 69620
Min. Negotiated Rate	$288.19
Max. Negotiated Rate	$901.50
Rate for Payer: Aetna Commercial	$551.61
Rate for Payer: Aetna Medicare	$601.00
Rate for Payer: BCBS Complete	$302.60
Rate for Payer: BCN Commercial	$747.47
Rate for Payer: Cash Price	$961.60
Rate for Payer: Cash Price	$961.60
Rate for Payer: Mclaren Medicaid	$288.19
Rate for Payer: Meridian Medicaid	$302.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$901.50
Rate for Payer: Priority Health Choice Medicaid	$288.19
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$738.57
Rate for Payer: Priority Health Narrow/Tiered Network	$738.57
Rate for Payer: UHC Medicaid	$288.19
Rate for Payer: UHCCP Medicaid	$288.19

PR MYRINGOTOMY ASPIR&/EUSTACHIAN TUBE NFLTJ

Professional

Both

$327.00

Service Code	HCPCS 69420
Min. Negotiated Rate	$70.50
Max. Negotiated Rate	$245.25
Rate for Payer: Aetna Commercial	$133.05
Rate for Payer: Aetna Medicare	$163.50
Rate for Payer: BCBS Complete	$74.03
Rate for Payer: BCN Commercial	$182.76
Rate for Payer: Cash Price	$261.60
Rate for Payer: Cash Price	$261.60
Rate for Payer: Mclaren Medicaid	$70.50
Rate for Payer: Meridian Medicaid	$74.03
Rate for Payer: Opus (Opus Packaging Group) HMA	$245.25
Rate for Payer: Priority Health Choice Medicaid	$70.50
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$180.58
Rate for Payer: Priority Health Narrow/Tiered Network	$180.58
Rate for Payer: UHC Medicaid	$70.50
Rate for Payer: UHCCP Medicaid	$70.50

Know your out-of-pocket cost for care.

All Charges