Bronson Lakeview Hospital

All Charges

Charge

Type

Setting

Price

PR NJX DX/THER AGT PVRT FACET JT CRV/THRC 3+ LEVEL

Professional

Both

$218.00

Service Code	HCPCS 64492
Min. Negotiated Rate	$32.59
Max. Negotiated Rate	$163.50
Rate for Payer: Aetna Commercial	$79.05
Rate for Payer: Aetna Medicare	$109.00
Rate for Payer: BCBS Complete	$34.22
Rate for Payer: BCN Commercial	$89.14
Rate for Payer: Cash Price	$174.40
Rate for Payer: Cash Price	$174.40
Rate for Payer: Mclaren Medicaid	$32.59
Rate for Payer: Meridian Medicaid	$34.22
Rate for Payer: Opus (Opus Packaging Group) HMA	$163.50
Rate for Payer: Priority Health Choice Medicaid	$32.59
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$103.53
Rate for Payer: Priority Health Narrow/Tiered Network	$103.53
Rate for Payer: UHC Medicaid	$32.59
Rate for Payer: UHCCP Medicaid	$32.59

PR NJX DX/THER AGT PVRT FACET JT LMBR/SAC 1 LEVEL

Professional

Both

$249.00

Service Code	HCPCS 64493
Min. Negotiated Rate	$51.97
Max. Negotiated Rate	$186.75
Rate for Payer: Aetna Commercial	$115.69
Rate for Payer: Aetna Medicare	$124.50
Rate for Payer: BCBS Complete	$54.57
Rate for Payer: BCN Commercial	$135.95
Rate for Payer: Cash Price	$199.20
Rate for Payer: Cash Price	$199.20
Rate for Payer: Mclaren Medicaid	$51.97
Rate for Payer: Meridian Medicaid	$54.57
Rate for Payer: Opus (Opus Packaging Group) HMA	$186.75
Rate for Payer: Priority Health Choice Medicaid	$51.97
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$157.91
Rate for Payer: Priority Health Narrow/Tiered Network	$157.91
Rate for Payer: UHC Medicaid	$51.97
Rate for Payer: UHCCP Medicaid	$51.97

PR NJX DX/THER AGT PVRT FACET JT LMBR/SAC 2ND LEVEL

Professional

Both

$172.00

Service Code	HCPCS 64494
Min. Negotiated Rate	$27.90
Max. Negotiated Rate	$129.00
Rate for Payer: Aetna Commercial	$66.74
Rate for Payer: Aetna Medicare	$86.00
Rate for Payer: BCBS Complete	$29.30
Rate for Payer: BCN Commercial	$75.70
Rate for Payer: Cash Price	$137.60
Rate for Payer: Cash Price	$137.60
Rate for Payer: Mclaren Medicaid	$27.90
Rate for Payer: Meridian Medicaid	$29.30
Rate for Payer: Opus (Opus Packaging Group) HMA	$129.00
Rate for Payer: Priority Health Choice Medicaid	$27.90
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$87.92
Rate for Payer: Priority Health Narrow/Tiered Network	$87.92
Rate for Payer: UHC Medicaid	$27.90
Rate for Payer: UHCCP Medicaid	$27.90

PR NJX DX/THER AGT PVRT FACET JT LMBR/SAC 3+ LEVEL

Professional

Both

$176.00

Service Code	HCPCS 64495
Min. Negotiated Rate	$28.76
Max. Negotiated Rate	$132.00
Rate for Payer: Aetna Commercial	$67.57
Rate for Payer: Aetna Medicare	$88.00
Rate for Payer: BCBS Complete	$30.20
Rate for Payer: BCN Commercial	$76.19
Rate for Payer: Cash Price	$140.80
Rate for Payer: Cash Price	$140.80
Rate for Payer: Mclaren Medicaid	$28.76
Rate for Payer: Meridian Medicaid	$30.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$132.00
Rate for Payer: Priority Health Choice Medicaid	$28.76
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$88.49
Rate for Payer: Priority Health Narrow/Tiered Network	$88.49
Rate for Payer: UHC Medicaid	$28.76
Rate for Payer: UHCCP Medicaid	$28.76

PR NJX DX/THER SBST EPIDURAL/SUBARACH LUMBAR/SACRAL

Professional

Both

$781.00

Service Code	HCPCS 62311
Min. Negotiated Rate	$312.40
Max. Negotiated Rate	$585.75
Rate for Payer: Aetna Medicare	$390.50
Rate for Payer: BCBS Complete	$312.40
Rate for Payer: Cash Price	$624.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$585.75

PR NJX DX/THER SBST EPIDURAL/SUBRACH CERV/THORACIC

Professional

Both

$694.00

Service Code	HCPCS 62310
Min. Negotiated Rate	$277.60
Max. Negotiated Rate	$520.50
Rate for Payer: Aetna Medicare	$347.00
Rate for Payer: BCBS Complete	$277.60
Rate for Payer: Cash Price	$555.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$520.50

PR NJX DX/THER SBST INTRLMNR CRV/THRC W/IMG GDN

Professional

Both

$348.00

Service Code	HCPCS 62321
Min. Negotiated Rate	$60.92
Max. Negotiated Rate	$261.00
Rate for Payer: Aetna Commercial	$138.22
Rate for Payer: Aetna Medicare	$174.00
Rate for Payer: BCBS Complete	$63.97
Rate for Payer: BCN Commercial	$159.85
Rate for Payer: Cash Price	$278.40
Rate for Payer: Cash Price	$278.40
Rate for Payer: Mclaren Medicaid	$60.92
Rate for Payer: Meridian Medicaid	$63.97
Rate for Payer: Opus (Opus Packaging Group) HMA	$261.00
Rate for Payer: Priority Health Choice Medicaid	$60.92
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$185.66
Rate for Payer: Priority Health Narrow/Tiered Network	$185.66
Rate for Payer: UHC Medicaid	$60.92
Rate for Payer: UHCCP Medicaid	$60.92

PR NJX DX/THER SBST INTRLMNR LMBR/SAC W/IMG GDN

Professional

Both

$317.00

Service Code	HCPCS 62323
Min. Negotiated Rate	$56.87
Max. Negotiated Rate	$237.75
Rate for Payer: Aetna Commercial	$127.22
Rate for Payer: Aetna Medicare	$158.50
Rate for Payer: BCBS Complete	$59.71
Rate for Payer: BCN Commercial	$147.90
Rate for Payer: Cash Price	$253.60
Rate for Payer: Cash Price	$253.60
Rate for Payer: Mclaren Medicaid	$56.87
Rate for Payer: Meridian Medicaid	$59.71
Rate for Payer: Opus (Opus Packaging Group) HMA	$237.75
Rate for Payer: Priority Health Choice Medicaid	$56.87
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$171.79
Rate for Payer: Priority Health Narrow/Tiered Network	$171.79
Rate for Payer: UHC Medicaid	$56.87
Rate for Payer: UHCCP Medicaid	$56.87

PR NJX INFUS/BOLUS DX/SBST EDRL/SUBARACH LUM/SACRAL

Professional

Both

$898.00

Service Code	HCPCS 62319
Min. Negotiated Rate	$359.20
Max. Negotiated Rate	$673.50
Rate for Payer: Aetna Medicare	$449.00
Rate for Payer: BCBS Complete	$359.20
Rate for Payer: Cash Price	$718.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$673.50

PR NJX NONCMPND SCLEROSANT MULTIPLE INCMPTNT VEINS

Professional

Both

$2,936.00

Service Code	HCPCS 36466
Min. Negotiated Rate	$84.99
Max. Negotiated Rate	$2,202.00
Rate for Payer: Aetna Commercial	$206.96
Rate for Payer: Aetna Medicare	$1,468.00
Rate for Payer: BCBS Complete	$89.24
Rate for Payer: BCN Commercial	$222.60
Rate for Payer: Cash Price	$2,348.80
Rate for Payer: Cash Price	$2,348.80
Rate for Payer: Mclaren Medicaid	$84.99
Rate for Payer: Meridian Medicaid	$89.24
Rate for Payer: Opus (Opus Packaging Group) HMA	$2,202.00
Rate for Payer: Priority Health Choice Medicaid	$84.99
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$239.38
Rate for Payer: Priority Health Narrow/Tiered Network	$239.38
Rate for Payer: UHC Medicaid	$84.99
Rate for Payer: UHCCP Medicaid	$84.99

PR NJX NONCMPND SCLEROSANT SINGLE INCMPTNT VEIN

Professional

Both

$2,780.00

Service Code	HCPCS 36465
Min. Negotiated Rate	$67.31
Max. Negotiated Rate	$2,085.00
Rate for Payer: Aetna Commercial	$160.20
Rate for Payer: Aetna Medicare	$1,390.00
Rate for Payer: BCBS Complete	$70.68
Rate for Payer: BCN Commercial	$176.28
Rate for Payer: Cash Price	$2,224.00
Rate for Payer: Cash Price	$2,224.00
Rate for Payer: Mclaren Medicaid	$67.31
Rate for Payer: Meridian Medicaid	$70.68
Rate for Payer: Opus (Opus Packaging Group) HMA	$2,085.00
Rate for Payer: Priority Health Choice Medicaid	$67.31
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$189.58
Rate for Payer: Priority Health Narrow/Tiered Network	$189.58
Rate for Payer: UHC Medicaid	$67.31
Rate for Payer: UHCCP Medicaid	$67.31

PR NJX PLTLT PLASMA W/IMG HARVEST/PREPARATION

Professional

Both

$946.00

Service Code	HCPCS 0232T
Min. Negotiated Rate	$128.61
Max. Negotiated Rate	$709.50
Rate for Payer: Aetna Commercial	$128.61
Rate for Payer: Aetna Commercial	$128.61
Rate for Payer: Aetna Medicare	$473.00
Rate for Payer: Aetna Medicare	$315.00
Rate for Payer: BCBS Complete	$252.00
Rate for Payer: BCBS Complete	$378.40
Rate for Payer: BCN Commercial	$373.10
Rate for Payer: BCN Commercial	$373.10
Rate for Payer: Cash Price	$504.00
Rate for Payer: Cash Price	$504.00
Rate for Payer: Cash Price	$756.80
Rate for Payer: Cash Price	$756.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$472.50
Rate for Payer: Opus (Opus Packaging Group) HMA	$709.50
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$271.50
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$271.50
Rate for Payer: Priority Health Narrow/Tiered Network	$271.50
Rate for Payer: Priority Health Narrow/Tiered Network	$271.50

PR NJX PX ANTEGRDE NFROSGRM &/URTRGRM EXSTNG ACESS

Professional

Both

$213.00

Service Code	HCPCS 50431
Min. Negotiated Rate	$37.70
Max. Negotiated Rate	$159.75
Rate for Payer: Aetna Commercial	$82.85
Rate for Payer: Aetna Medicare	$106.50
Rate for Payer: BCBS Complete	$39.59
Rate for Payer: BCN Commercial	$98.60
Rate for Payer: Cash Price	$170.40
Rate for Payer: Cash Price	$170.40
Rate for Payer: Mclaren Medicaid	$37.70
Rate for Payer: Meridian Medicaid	$39.59
Rate for Payer: Opus (Opus Packaging Group) HMA	$159.75
Rate for Payer: Priority Health Choice Medicaid	$37.70
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$107.41
Rate for Payer: Priority Health Narrow/Tiered Network	$107.41
Rate for Payer: UHC Medicaid	$37.70
Rate for Payer: UHCCP Medicaid	$37.70

PR NJX PX ANTEGRDE NFROSGRM &/URTRGRM NEW ACCESS

Professional

Both

$247.00

Service Code	HCPCS 50430
Min. Negotiated Rate	$86.48
Max. Negotiated Rate	$246.27
Rate for Payer: Aetna Commercial	$196.43
Rate for Payer: Aetna Medicare	$123.50
Rate for Payer: BCBS Complete	$90.80
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	$86.48
Rate for Payer: Meridian Medicaid	$90.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$185.25
Rate for Payer: Priority Health Choice Medicaid	$86.48
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$246.27
Rate for Payer: Priority Health Narrow/Tiered Network	$246.27
Rate for Payer: UHC Medicaid	$86.48
Rate for Payer: UHCCP Medicaid	$86.48

PR NJX PX XTR VNGRPH W/INTRO NDL/INTRACATH

Professional

Both

$592.00

Service Code	HCPCS 36005
Min. Negotiated Rate	$26.63
Max. Negotiated Rate	$444.00
Rate for Payer: Aetna Commercial	$64.54
Rate for Payer: Aetna Medicare	$296.00
Rate for Payer: BCBS Complete	$27.96
Rate for Payer: BCN Commercial	$76.59
Rate for Payer: Cash Price	$473.60
Rate for Payer: Cash Price	$473.60
Rate for Payer: Mclaren Medicaid	$26.63
Rate for Payer: Meridian Medicaid	$27.96
Rate for Payer: Opus (Opus Packaging Group) HMA	$444.00
Rate for Payer: Priority Health Choice Medicaid	$26.63
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$74.98
Rate for Payer: Priority Health Narrow/Tiered Network	$74.98
Rate for Payer: UHC Medicaid	$26.63
Rate for Payer: UHCCP Medicaid	$26.63

PR NJX RETROGRADE URETHROCSTOGRAPY

Professional

Both

$739.00

Service Code	HCPCS 51610
Min. Negotiated Rate	$36.85
Max. Negotiated Rate	$554.25
Rate for Payer: Aetna Commercial	$81.03
Rate for Payer: Aetna Medicare	$369.50
Rate for Payer: BCBS Complete	$38.69
Rate for Payer: BCN Commercial	$97.11
Rate for Payer: Cash Price	$591.20
Rate for Payer: Cash Price	$591.20
Rate for Payer: Mclaren Medicaid	$36.85
Rate for Payer: Meridian Medicaid	$38.69
Rate for Payer: Opus (Opus Packaging Group) HMA	$554.25
Rate for Payer: Priority Health Choice Medicaid	$36.85
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$105.79
Rate for Payer: Priority Health Narrow/Tiered Network	$105.79
Rate for Payer: UHC Medicaid	$36.85
Rate for Payer: UHCCP Medicaid	$36.85

PR NJX VISUALIZATION ILEAL CONDUIT&/URETEROPYELOG

Professional

Both

$219.00

Service Code	HCPCS 50690
Min. Negotiated Rate	$39.62
Max. Negotiated Rate	$164.25
Rate for Payer: Aetna Commercial	$88.08
Rate for Payer: Aetna Medicare	$109.50
Rate for Payer: BCBS Complete	$41.60
Rate for Payer: BCN Commercial	$105.08
Rate for Payer: Cash Price	$175.20
Rate for Payer: Cash Price	$175.20
Rate for Payer: Mclaren Medicaid	$39.62
Rate for Payer: Meridian Medicaid	$41.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$164.25
Rate for Payer: Priority Health Choice Medicaid	$39.62
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$114.46
Rate for Payer: Priority Health Narrow/Tiered Network	$114.46
Rate for Payer: UHC Medicaid	$39.62
Rate for Payer: UHCCP Medicaid	$39.62

PR NOCTURNAL PENILE TUMESCENCE &/RIGIDITY TEST

Professional

Both

$242.00

Service Code	HCPCS 54250
Min. Negotiated Rate	$96.80
Max. Negotiated Rate	$197.45
Rate for Payer: Aetna Commercial	$155.80
Rate for Payer: Aetna Medicare	$121.00
Rate for Payer: BCBS Complete	$96.80
Rate for Payer: BCN Commercial	$181.27
Rate for Payer: Cash Price	$193.60
Rate for Payer: Cash Price	$193.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$181.50
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$197.45
Rate for Payer: Priority Health Narrow/Tiered Network	$197.45

PR NONINVASIVE EAR/PULSE OXIMETRY MULTIPLE DETER

Professional

Both

$49.00

Service Code	HCPCS 94761
Min. Negotiated Rate	$3.94
Max. Negotiated Rate	$36.75
Rate for Payer: Aetna Commercial	$3.94
Rate for Payer: Aetna Medicare	$24.50
Rate for Payer: BCBS Complete	$19.60
Rate for Payer: BCN Commercial	$5.97
Rate for Payer: Cash Price	$39.20
Rate for Payer: Cash Price	$39.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$36.75
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$5.51
Rate for Payer: Priority Health Narrow/Tiered Network	$5.51

PR NONINVASIVE EAR/PULSE OXIMETRY OVERNIGHT MONITOR

Professional

Both

$43.00

Service Code	HCPCS 94762
Min. Negotiated Rate	$17.20
Max. Negotiated Rate	$36.85
Rate for Payer: Aetna Commercial	$28.15
Rate for Payer: Aetna Medicare	$21.50
Rate for Payer: BCBS Complete	$17.20
Rate for Payer: BCN Commercial	$36.85
Rate for Payer: Cash Price	$34.40
Rate for Payer: Cash Price	$34.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$32.25
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$33.99
Rate for Payer: Priority Health Narrow/Tiered Network	$33.99

PR NONINVASIVE EAR/PULSE OXIMETRY SINGLE DETER

Professional

Both

$46.00

Service Code	HCPCS 94760
Min. Negotiated Rate	$2.52
Max. Negotiated Rate	$34.50
Rate for Payer: Aetna Commercial	$2.52
Rate for Payer: Aetna Medicare	$23.00
Rate for Payer: BCBS Complete	$18.40
Rate for Payer: BCN Commercial	$5.48
Rate for Payer: Cash Price	$36.80
Rate for Payer: Cash Price	$36.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$34.50
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$5.05
Rate for Payer: Priority Health Narrow/Tiered Network	$5.05

PR NON-INVASIVE PHYSIOLOGIC STUDY EXTREMITY 3 LEVLS

Professional

Both

$46.00

Service Code	HCPCS 93923
Min. Negotiated Rate	$23.00
Max. Negotiated Rate	$193.71
Rate for Payer: Aetna Commercial	$139.53
Rate for Payer: Aetna Commercial	$139.53
Rate for Payer: Aetna Medicare	$162.00
Rate for Payer: Aetna Medicare	$23.00
Rate for Payer: BCN Commercial	$193.71
Rate for Payer: BCN Commercial	$193.71
Rate for Payer: Cash Price	$36.80
Rate for Payer: Cash Price	$259.20
Rate for Payer: Cash Price	$36.80
Rate for Payer: Cash Price	$259.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$34.50
Rate for Payer: Opus (Opus Packaging Group) HMA	$243.00
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$178.65
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$178.65
Rate for Payer: Priority Health Narrow/Tiered Network	$178.65
Rate for Payer: Priority Health Narrow/Tiered Network	$178.65

PR NON-INVAS PHYSIOLOGIC STD EXTREMITY ART 2 LEVEL

Professional

Both

$28.00

Service Code	HCPCS 93922
Min. Negotiated Rate	$14.00
Max. Negotiated Rate	$122.01
Rate for Payer: Aetna Commercial	$90.01
Rate for Payer: Aetna Commercial	$90.01
Rate for Payer: Aetna Medicare	$105.50
Rate for Payer: Aetna Medicare	$14.00
Rate for Payer: BCN Commercial	$122.01
Rate for Payer: BCN Commercial	$122.01
Rate for Payer: Cash Price	$168.80
Rate for Payer: Cash Price	$22.40
Rate for Payer: Cash Price	$22.40
Rate for Payer: Cash Price	$168.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$158.25
Rate for Payer: Opus (Opus Packaging Group) HMA	$21.00
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$112.52
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$112.52
Rate for Payer: Priority Health Narrow/Tiered Network	$112.52
Rate for Payer: Priority Health Narrow/Tiered Network	$112.52

PR NONSLCTV CATH THOR AORTA ANGIO INTR/XTRCRANL ART

Professional

Both

$1,174.00

Service Code	HCPCS 36221
Min. Negotiated Rate	$113.53
Max. Negotiated Rate	$880.50
Rate for Payer: Aetna Commercial	$269.74
Rate for Payer: Aetna Medicare	$587.00
Rate for Payer: BCBS Complete	$119.21
Rate for Payer: BCN Commercial	$292.32
Rate for Payer: Cash Price	$939.20
Rate for Payer: Cash Price	$939.20
Rate for Payer: Mclaren Medicaid	$113.53
Rate for Payer: Meridian Medicaid	$119.21
Rate for Payer: Opus (Opus Packaging Group) HMA	$880.50
Rate for Payer: Priority Health Choice Medicaid	$113.53
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$314.34
Rate for Payer: Priority Health Narrow/Tiered Network	$314.34
Rate for Payer: UHC Medicaid	$113.53
Rate for Payer: UHCCP Medicaid	$113.53

PR NORMAL SALINE SOLUTION INFUS

Professional

Both

$10.00

Service Code	HCPCS J7030
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$7.50
Rate for Payer: Aetna Commercial	$2.77
Rate for Payer: Aetna Medicare	$5.00
Rate for Payer: BCBS Trust/PPO	$0.45
Rate for Payer: BCN Commercial	$0.58
Rate for Payer: Cash Price	$8.00
Rate for Payer: Cash Price	$8.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$7.50

Know your out-of-pocket cost for care.

All Charges