Bronson Lakeview Hospital

All Charges

Charge

Type

Setting

Price

PR MEDICATION THERAPY INITIAL 15 MIN ESTABLISHED PT

Professional

Both

$32.00

Service Code	HCPCS 99606
Min. Negotiated Rate	$12.80
Max. Negotiated Rate	$20.80
Rate for Payer: Aetna Medicare	$16.00
Rate for Payer: BCBS Complete	$12.80
Rate for Payer: Cash Price	$25.60
Rate for Payer: Priority Health Cigna Priority Health	$20.80

PR MEDICATION THERAPY INITIAL 15 MIN NEW PATIENT

Professional

Both

$64.00

Service Code	HCPCS 99605
Min. Negotiated Rate	$25.60
Max. Negotiated Rate	$41.60
Rate for Payer: Aetna Medicare	$32.00
Rate for Payer: BCBS Complete	$25.60
Rate for Payer: Cash Price	$51.20
Rate for Payer: Priority Health Cigna Priority Health	$41.60

PR MEDROXYPROGESTERONE ACETATE

Professional

Both

$1.00

Service Code	HCPCS J1050
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.65
Rate for Payer: Aetna Medicare	$0.50
Rate for Payer: BCBS Complete	$0.40
Rate for Payer: Cash Price	$0.80
Rate for Payer: Priority Health Cigna Priority Health	$0.65

PR MEDROXYPROGESTERONE INJ

Professional

Both

$31.00

Service Code	HCPCS J1051
Min. Negotiated Rate	$12.40
Max. Negotiated Rate	$20.15
Rate for Payer: Aetna Medicare	$15.50
Rate for Payer: BCBS Complete	$12.40
Rate for Payer: Cash Price	$24.80
Rate for Payer: Priority Health Cigna Priority Health	$20.15

PR MEDRXYPROGESTER ACETATE INJ

Professional

Both

$82.00

Service Code	HCPCS J1055
Min. Negotiated Rate	$32.80
Max. Negotiated Rate	$53.30
Rate for Payer: Aetna Medicare	$41.00
Rate for Payer: BCBS Complete	$32.80
Rate for Payer: Cash Price	$65.60
Rate for Payer: Priority Health Cigna Priority Health	$53.30

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

Professional

Both

$143.00

Service Code	HCPCS 90734
Min. Negotiated Rate	$57.20
Max. Negotiated Rate	$92.95
Rate for Payer: Aetna Medicare	$71.50
Rate for Payer: BCBS Complete	$57.20
Rate for Payer: Cash Price	$114.40
Rate for Payer: Priority Health Cigna Priority Health	$92.95

PR MENACWY-TT CONJ VACC SEROGROUPS ACWY FOR IM USE

Professional

Both

$184.00

Service Code	HCPCS 90619
Min. Negotiated Rate	$73.60
Max. Negotiated Rate	$119.60
Rate for Payer: Aetna Medicare	$92.00
Rate for Payer: BCBS Complete	$73.60
Rate for Payer: Cash Price	$147.20
Rate for Payer: Priority Health Cigna Priority Health	$119.60

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

Professional

Both

$263.00

Service Code	HCPCS 90620
Min. Negotiated Rate	$105.20
Max. Negotiated Rate	$170.95
Rate for Payer: Aetna Medicare	$131.50
Rate for Payer: BCBS Complete	$105.20
Rate for Payer: Cash Price	$210.40
Rate for Payer: Priority Health Cigna Priority Health	$170.95

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

Professional

Both

$184.00

Service Code	HCPCS 90621
Min. Negotiated Rate	$73.60
Max. Negotiated Rate	$119.60
Rate for Payer: Aetna Medicare	$92.00
Rate for Payer: BCBS Complete	$73.60
Rate for Payer: Cash Price	$147.20
Rate for Payer: Priority Health Cigna Priority Health	$119.60

PR MEPERIDINE HYDROCHL /100 MG

Professional

Both

$10.00

Service Code	HCPCS J2175
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$22.59
Rate for Payer: Aetna Commercial	$21.02
Rate for Payer: Aetna Medicare	$16.32
Rate for Payer: BCBS Complete	$4.00
Rate for Payer: BCBS MAPPO	$15.69
Rate for Payer: BCN Medicare Advantage	$15.69
Rate for Payer: Cash Price	$8.00
Rate for Payer: Cash Price	$8.00
Rate for Payer: Cofinity Commercial	$22.59
Rate for Payer: Cofinity Commercial	$21.02
Rate for Payer: Health Alliance Plan Medicare Advantage	$15.69
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$16.47
Rate for Payer: Nomi Health Commercial	$18.83
Rate for Payer: PACE SWMI	$15.69
Rate for Payer: PHP Medicare Advantage	$15.69
Rate for Payer: Priority Health Cigna Priority Health	$6.50
Rate for Payer: Priority Health Medicare	$15.85
Rate for Payer: UHC All Payor (Choice/PPO)	$15.69
Rate for Payer: UHC Dual Complete DSNP	$15.69
Rate for Payer: UHC Exchange	$15.69
Rate for Payer: UHC Medicare Advantage	$15.69

PR MEPERIDINE/PROMETHAZINE INJ

Professional

Both

$11.00

Service Code	HCPCS J2180
Min. Negotiated Rate	$4.40
Max. Negotiated Rate	$7.15
Rate for Payer: Aetna Medicare	$5.50
Rate for Payer: BCBS Complete	$4.40
Rate for Payer: Cash Price	$8.80
Rate for Payer: Priority Health Cigna Priority Health	$7.15

PR METATARSECTOMY

Professional

Both

$1,071.00

Service Code	HCPCS 28140
Min. Negotiated Rate	$407.56
Max. Negotiated Rate	$696.15
Rate for Payer: Aetna Commercial	$546.13
Rate for Payer: Aetna Medicare	$423.86
Rate for Payer: BCBS Complete	$428.40
Rate for Payer: BCBS MAPPO	$407.56
Rate for Payer: BCN Medicare Advantage	$407.56
Rate for Payer: Cash Price	$856.80
Rate for Payer: Cash Price	$856.80
Rate for Payer: Cofinity Commercial	$546.13
Rate for Payer: Cofinity Commercial	$586.89
Rate for Payer: Health Alliance Plan Medicare Advantage	$407.56
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$427.94
Rate for Payer: Nomi Health Commercial	$489.07
Rate for Payer: PACE SWMI	$407.56
Rate for Payer: PHP Medicare Advantage	$407.56
Rate for Payer: Priority Health Cigna Priority Health	$696.15
Rate for Payer: Priority Health Medicare	$411.64
Rate for Payer: UHC All Payor (Choice/PPO)	$407.56
Rate for Payer: UHC Dual Complete DSNP	$407.56
Rate for Payer: UHC Exchange	$407.56
Rate for Payer: UHC Medicare Advantage	$407.56

PR METHYLPREDNISOLONE 20 MG INJ

Professional

Both

$10.00

Service Code	HCPCS J1020
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$6.50
Rate for Payer: Aetna Medicare	$5.00
Rate for Payer: BCBS Complete	$4.00
Rate for Payer: Cash Price	$8.00
Rate for Payer: Priority Health Cigna Priority Health	$6.50

PR METHYLPREDNISOLONE 40 MG INJ

Professional

Both

$15.00

Service Code	HCPCS J1030
Min. Negotiated Rate	$6.00
Max. Negotiated Rate	$9.75
Rate for Payer: Aetna Medicare	$7.50
Rate for Payer: BCBS Complete	$6.00
Rate for Payer: Cash Price	$12.00
Rate for Payer: Priority Health Cigna Priority Health	$9.75

PR METHYLPREDNISOLONE 80 MG INJ

Professional

Both

$26.00

Service Code	HCPCS J1040
Min. Negotiated Rate	$10.40
Max. Negotiated Rate	$16.90
Rate for Payer: Aetna Medicare	$13.00
Rate for Payer: BCBS Complete	$10.40
Rate for Payer: Cash Price	$20.80
Rate for Payer: Priority Health Cigna Priority Health	$16.90

PR METHYLPREDNISOLONE INJECTION

Professional

Both

$26.00

Service Code	HCPCS J2930
Min. Negotiated Rate	$10.40
Max. Negotiated Rate	$16.90
Rate for Payer: Aetna Medicare	$13.00
Rate for Payer: BCBS Complete	$10.40
Rate for Payer: Cash Price	$20.80
Rate for Payer: Priority Health Cigna Priority Health	$16.90

PR METHYLPREDNISOLONE INJECTION

Professional

Both

$10.00

Service Code	HCPCS J2920
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$6.50
Rate for Payer: Aetna Medicare	$5.00
Rate for Payer: BCBS Complete	$4.00
Rate for Payer: Cash Price	$8.00
Rate for Payer: Priority Health Cigna Priority Health	$6.50

PR MGMT LVR HEMRRG CPLX SUTR WND/INJ

Professional

Both

$3,454.00

Service Code	HCPCS 47360
Min. Negotiated Rate	$1,381.60
Max. Negotiated Rate	$2,618.55
Rate for Payer: Aetna Commercial	$2,436.71
Rate for Payer: Aetna Medicare	$1,891.18
Rate for Payer: BCBS Complete	$1,381.60
Rate for Payer: BCBS MAPPO	$1,818.44
Rate for Payer: BCN Medicare Advantage	$1,818.44
Rate for Payer: Cash Price	$2,763.20
Rate for Payer: Cash Price	$2,763.20
Rate for Payer: Cofinity Commercial	$2,436.71
Rate for Payer: Cofinity Commercial	$2,618.55
Rate for Payer: Health Alliance Plan Medicare Advantage	$1,818.44
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$1,909.36
Rate for Payer: Nomi Health Commercial	$2,182.13
Rate for Payer: PACE SWMI	$1,818.44
Rate for Payer: PHP Medicare Advantage	$1,818.44
Rate for Payer: Priority Health Cigna Priority Health	$2,245.10
Rate for Payer: Priority Health Medicare	$1,836.62
Rate for Payer: UHC All Payor (Choice/PPO)	$1,818.44
Rate for Payer: UHC Dual Complete DSNP	$1,818.44
Rate for Payer: UHC Exchange	$1,818.44
Rate for Payer: UHC Medicare Advantage	$1,818.44

PR MGMT LVR HEMRRG EXPL WND DBRDMT COAGJ/SUTR

Professional

Both

$6,375.00

Service Code	HCPCS 47361
Min. Negotiated Rate	$2,550.00
Max. Negotiated Rate	$4,200.35
Rate for Payer: Aetna Commercial	$3,908.66
Rate for Payer: Aetna Medicare	$3,033.59
Rate for Payer: BCBS Complete	$2,550.00
Rate for Payer: BCBS MAPPO	$2,916.91
Rate for Payer: BCN Medicare Advantage	$2,916.91
Rate for Payer: Cash Price	$5,100.00
Rate for Payer: Cash Price	$5,100.00
Rate for Payer: Cofinity Commercial	$4,200.35
Rate for Payer: Cofinity Commercial	$3,908.66
Rate for Payer: Health Alliance Plan Medicare Advantage	$2,916.91
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$3,062.76
Rate for Payer: Nomi Health Commercial	$3,500.29
Rate for Payer: PACE SWMI	$2,916.91
Rate for Payer: PHP Medicare Advantage	$2,916.91
Rate for Payer: Priority Health Cigna Priority Health	$4,143.75
Rate for Payer: Priority Health Medicare	$2,946.08
Rate for Payer: UHC All Payor (Choice/PPO)	$2,916.91
Rate for Payer: UHC Dual Complete DSNP	$2,916.91
Rate for Payer: UHC Exchange	$2,916.91
Rate for Payer: UHC Medicare Advantage	$2,916.91

PR MGMT LVR HEMRRG RE-EXPL WND RMVL PACKING

Professional

Both

$2,999.00

Service Code	HCPCS 47362
Min. Negotiated Rate	$1,199.60
Max. Negotiated Rate	$1,977.09
Rate for Payer: Aetna Commercial	$1,839.79
Rate for Payer: Aetna Medicare	$1,427.90
Rate for Payer: BCBS Complete	$1,199.60
Rate for Payer: BCBS MAPPO	$1,372.98
Rate for Payer: BCN Medicare Advantage	$1,372.98
Rate for Payer: Cash Price	$2,399.20
Rate for Payer: Cash Price	$2,399.20
Rate for Payer: Cofinity Commercial	$1,977.09
Rate for Payer: Cofinity Commercial	$1,839.79
Rate for Payer: Health Alliance Plan Medicare Advantage	$1,372.98
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$1,441.63
Rate for Payer: Nomi Health Commercial	$1,647.58
Rate for Payer: PACE SWMI	$1,372.98
Rate for Payer: PHP Medicare Advantage	$1,372.98
Rate for Payer: Priority Health Cigna Priority Health	$1,949.35
Rate for Payer: Priority Health Medicare	$1,386.71
Rate for Payer: UHC All Payor (Choice/PPO)	$1,372.98
Rate for Payer: UHC Dual Complete DSNP	$1,372.98
Rate for Payer: UHC Exchange	$1,372.98
Rate for Payer: UHC Medicare Advantage	$1,372.98

PR MGMT LVR HEMRRG SMPL SUTR LVR WND/INJ

Professional

Both

$2,903.00

Service Code	HCPCS 47350
Min. Negotiated Rate	$1,161.20
Max. Negotiated Rate	$1,897.50
Rate for Payer: Aetna Commercial	$1,765.73
Rate for Payer: Aetna Medicare	$1,370.42
Rate for Payer: BCBS Complete	$1,161.20
Rate for Payer: BCBS MAPPO	$1,317.71
Rate for Payer: BCN Medicare Advantage	$1,317.71
Rate for Payer: Cash Price	$2,322.40
Rate for Payer: Cash Price	$2,322.40
Rate for Payer: Cofinity Commercial	$1,897.50
Rate for Payer: Cofinity Commercial	$1,765.73
Rate for Payer: Health Alliance Plan Medicare Advantage	$1,317.71
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$1,383.60
Rate for Payer: Nomi Health Commercial	$1,581.25
Rate for Payer: PACE SWMI	$1,317.71
Rate for Payer: PHP Medicare Advantage	$1,317.71
Rate for Payer: Priority Health Cigna Priority Health	$1,886.95
Rate for Payer: Priority Health Medicare	$1,330.89
Rate for Payer: UHC All Payor (Choice/PPO)	$1,317.71
Rate for Payer: UHC Dual Complete DSNP	$1,317.71
Rate for Payer: UHC Exchange	$1,317.71
Rate for Payer: UHC Medicare Advantage	$1,317.71

PR MH PARTIAL HOSP TX UNDER 24H

Professional

Both

$259.00

Service Code	HCPCS H0035
Min. Negotiated Rate	$103.60
Max. Negotiated Rate	$168.35
Rate for Payer: Aetna Medicare	$129.50
Rate for Payer: BCBS Complete	$103.60
Rate for Payer: Cash Price	$207.20
Rate for Payer: Priority Health Cigna Priority Health	$168.35

PR MICRONEEDLING PIN ADB/THIGHS/BACK

Professional

Both

$459.00

Service Code	HCPCS 00108
Hospital Revenue Code	990
Min. Negotiated Rate	$183.60
Max. Negotiated Rate	$298.35
Rate for Payer: Aetna Medicare	$229.50
Rate for Payer: BCBS Complete	$183.60
Rate for Payer: Cash Price	$367.20
Rate for Payer: Priority Health Cigna Priority Health	$298.35

PR MICRONEEDLING PIN FULL FACE

Professional

Both

$408.00

Service Code	HCPCS 00105
Hospital Revenue Code	990
Min. Negotiated Rate	$163.20
Max. Negotiated Rate	$265.20
Rate for Payer: Aetna Medicare	$204.00
Rate for Payer: BCBS Complete	$163.20
Rate for Payer: Cash Price	$326.40
Rate for Payer: Priority Health Cigna Priority Health	$265.20

PR MICRONEEDLING PIN NECK

Professional

Both

$153.00

Service Code	HCPCS 00107
Hospital Revenue Code	990
Min. Negotiated Rate	$61.20
Max. Negotiated Rate	$99.45
Rate for Payer: Aetna Medicare	$76.50
Rate for Payer: BCBS Complete	$61.20
Rate for Payer: Cash Price	$122.40
Rate for Payer: Priority Health Cigna Priority Health	$99.45

Know your out-of-pocket cost for care.

All Charges