Bronson Lakeview Hospital

All Charges

Charge

Type

Setting

Price

PR SARSCOV2 VACCINE 25 MCG/0.25 ML FOR IM USE

Professional

Both

$356.00

Service Code	HCPCS 91321
Min. Negotiated Rate	$126.93
Max. Negotiated Rate	$267.00
Rate for Payer: Aetna Commercial	$145.92
Rate for Payer: Aetna Medicare	$178.00
Rate for Payer: BCBS Trust/PPO	$129.00
Rate for Payer: BCN Commercial	$126.93
Rate for Payer: Cash Price	$284.80
Rate for Payer: Cash Price	$284.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$267.00

PR SBSQ HOSPITAL IP/OBS CARE HIGH MDM 50 MINUTES

Professional

Both

$190.00

Service Code	HCPCS 99233
Min. Negotiated Rate	$68.16
Max. Negotiated Rate	$157.68
Rate for Payer: Aetna Commercial	$101.64
Rate for Payer: Aetna Medicare	$95.00
Rate for Payer: BCBS Complete	$71.57
Rate for Payer: BCN Commercial	$127.86
Rate for Payer: Cash Price	$152.00
Rate for Payer: Cash Price	$152.00
Rate for Payer: Mclaren Medicaid	$68.16
Rate for Payer: Meridian Medicaid	$71.57
Rate for Payer: Opus (Opus Packaging Group) HMA	$142.50
Rate for Payer: Priority Health Choice Medicaid	$68.16
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$157.68
Rate for Payer: Priority Health Narrow/Tiered Network	$157.68
Rate for Payer: UHC Medicaid	$68.16
Rate for Payer: UHCCP Medicaid	$68.16

PR SBSQ HOSPITAL IP/OBS CARE MOD MDM 35 MINUTES

Professional

Both

$133.00

Service Code	HCPCS 99232
Min. Negotiated Rate	$44.94
Max. Negotiated Rate	$105.71
Rate for Payer: Aetna Commercial	$70.74
Rate for Payer: Aetna Medicare	$66.50
Rate for Payer: BCBS Complete	$47.19
Rate for Payer: BCN Commercial	$85.73
Rate for Payer: Cash Price	$106.40
Rate for Payer: Cash Price	$106.40
Rate for Payer: Mclaren Medicaid	$44.94
Rate for Payer: Meridian Medicaid	$47.19
Rate for Payer: Opus (Opus Packaging Group) HMA	$99.75
Rate for Payer: Priority Health Choice Medicaid	$44.94
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$105.71
Rate for Payer: Priority Health Narrow/Tiered Network	$105.71
Rate for Payer: UHC Medicaid	$44.94
Rate for Payer: UHCCP Medicaid	$44.94

PR SBSQ HOSPITAL IP/OBS CARE SF/LOW MDM 25 MINUTES

Professional

Both

$80.00

Service Code	HCPCS 99231
Min. Negotiated Rate	$28.12
Max. Negotiated Rate	$65.40
Rate for Payer: Aetna Commercial	$37.82
Rate for Payer: Aetna Medicare	$40.00
Rate for Payer: BCBS Complete	$29.53
Rate for Payer: BCN Commercial	$53.03
Rate for Payer: Cash Price	$64.00
Rate for Payer: Cash Price	$64.00
Rate for Payer: Mclaren Medicaid	$28.12
Rate for Payer: Meridian Medicaid	$29.53
Rate for Payer: Opus (Opus Packaging Group) HMA	$60.00
Rate for Payer: Priority Health Choice Medicaid	$28.12
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$65.40
Rate for Payer: Priority Health Narrow/Tiered Network	$65.40
Rate for Payer: UHC Medicaid	$28.12
Rate for Payer: UHCCP Medicaid	$28.12

PR SBSQ INTENSIVE CARE INFANT PBW 2,501-5,000 GRAMS

Professional

Both

$394.00

Service Code	HCPCS 99480
Min. Negotiated Rate	$100.46
Max. Negotiated Rate	$295.50
Rate for Payer: Aetna Commercial	$117.37
Rate for Payer: Aetna Medicare	$197.00
Rate for Payer: BCBS Complete	$105.48
Rate for Payer: BCN Commercial	$170.81
Rate for Payer: Cash Price	$315.20
Rate for Payer: Cash Price	$315.20
Rate for Payer: Mclaren Medicaid	$100.46
Rate for Payer: Meridian Medicaid	$105.48
Rate for Payer: Opus (Opus Packaging Group) HMA	$295.50
Rate for Payer: Priority Health Choice Medicaid	$100.46
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$153.65
Rate for Payer: Priority Health Narrow/Tiered Network	$153.65
Rate for Payer: UHC Medicaid	$100.46
Rate for Payer: UHCCP Medicaid	$100.46

PR SBSQ INTENSIVE CARE LBW INFANT 1,500-2,500 GRAMS

Professional

Both

$394.00

Service Code	HCPCS 99479
Min. Negotiated Rate	$104.41
Max. Negotiated Rate	$295.50
Rate for Payer: Aetna Commercial	$122.20
Rate for Payer: Aetna Medicare	$197.00
Rate for Payer: BCBS Complete	$109.63
Rate for Payer: BCN Commercial	$177.29
Rate for Payer: Cash Price	$315.20
Rate for Payer: Cash Price	$315.20
Rate for Payer: Mclaren Medicaid	$104.41
Rate for Payer: Meridian Medicaid	$109.63
Rate for Payer: Opus (Opus Packaging Group) HMA	$295.50
Rate for Payer: Priority Health Choice Medicaid	$104.41
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$159.46
Rate for Payer: Priority Health Narrow/Tiered Network	$159.46
Rate for Payer: UHC Medicaid	$104.41
Rate for Payer: UHCCP Medicaid	$104.41

PR SBSQ INTENSIVE CARE VLBW INFANT<1,500 GRAMS

Professional

Both

$289.00

Service Code	HCPCS 99478
Min. Negotiated Rate	$115.04
Max. Negotiated Rate	$216.75
Rate for Payer: Aetna Commercial	$134.24
Rate for Payer: Aetna Medicare	$144.50
Rate for Payer: BCBS Complete	$120.79
Rate for Payer: BCN Commercial	$195.21
Rate for Payer: Cash Price	$231.20
Rate for Payer: Cash Price	$231.20
Rate for Payer: Mclaren Medicaid	$115.04
Rate for Payer: Meridian Medicaid	$120.79
Rate for Payer: Opus (Opus Packaging Group) HMA	$216.75
Rate for Payer: Priority Health Choice Medicaid	$115.04
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$175.59
Rate for Payer: Priority Health Narrow/Tiered Network	$175.59
Rate for Payer: UHC Medicaid	$115.04
Rate for Payer: UHCCP Medicaid	$115.04

PR SBSQ NURSING FACILITY CARE HIGH MDM 45 MINUTES

Professional

Both

$210.00

Service Code	HCPCS 99310
Min. Negotiated Rate	$105.00
Max. Negotiated Rate	$228.57
Rate for Payer: Aetna Commercial	$131.98
Rate for Payer: Aetna Medicare	$105.00
Rate for Payer: BCBS Complete	$129.62
Rate for Payer: BCN Commercial	$228.57
Rate for Payer: Cash Price	$168.00
Rate for Payer: Cash Price	$168.00
Rate for Payer: Mclaren Medicaid	$123.45
Rate for Payer: Meridian Medicaid	$129.62
Rate for Payer: Opus (Opus Packaging Group) HMA	$157.50
Rate for Payer: Priority Health Choice Medicaid	$123.45
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$205.60
Rate for Payer: Priority Health Narrow/Tiered Network	$205.60
Rate for Payer: UHC Medicaid	$123.45
Rate for Payer: UHCCP Medicaid	$123.45

PR SBSQ NURSING FACILITY CARE LOW MDM 20 MINUTES

Professional

Both

$106.00

Service Code	HCPCS 99308
Min. Negotiated Rate	$53.00
Max. Negotiated Rate	$110.55
Rate for Payer: Aetna Commercial	$67.42
Rate for Payer: Aetna Medicare	$53.00
Rate for Payer: BCBS Complete	$62.64
Rate for Payer: BCN Commercial	$110.55
Rate for Payer: Cash Price	$84.80
Rate for Payer: Cash Price	$84.80
Rate for Payer: Mclaren Medicaid	$59.66
Rate for Payer: Meridian Medicaid	$62.64
Rate for Payer: Opus (Opus Packaging Group) HMA	$79.50
Rate for Payer: Priority Health Choice Medicaid	$59.66
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$105.05
Rate for Payer: Priority Health Narrow/Tiered Network	$105.05
Rate for Payer: UHC Medicaid	$59.66
Rate for Payer: UHCCP Medicaid	$59.66

PR SBSQ NURSING FACILITY CARE MOD MDM 30 MINUTES

Professional

Both

$141.00

Service Code	HCPCS 99309
Min. Negotiated Rate	$70.50
Max. Negotiated Rate	$160.35
Rate for Payer: Aetna Commercial	$88.90
Rate for Payer: Aetna Medicare	$70.50
Rate for Payer: BCBS Complete	$91.05
Rate for Payer: BCN Commercial	$160.35
Rate for Payer: Cash Price	$112.80
Rate for Payer: Cash Price	$112.80
Rate for Payer: Mclaren Medicaid	$86.71
Rate for Payer: Meridian Medicaid	$91.05
Rate for Payer: Opus (Opus Packaging Group) HMA	$105.75
Rate for Payer: Priority Health Choice Medicaid	$86.71
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$138.47
Rate for Payer: Priority Health Narrow/Tiered Network	$138.47
Rate for Payer: UHC Medicaid	$86.71
Rate for Payer: UHCCP Medicaid	$86.71

PR SBSQ NURSING FACILITY CARE SF MDM 10 MINUTES

Professional

Both

$69.00

Service Code	HCPCS 99307
Min. Negotiated Rate	$32.62
Max. Negotiated Rate	$59.26
Rate for Payer: Aetna Commercial	$42.96
Rate for Payer: Aetna Medicare	$34.50
Rate for Payer: BCBS Complete	$34.25
Rate for Payer: BCN Commercial	$59.26
Rate for Payer: Cash Price	$55.20
Rate for Payer: Cash Price	$55.20
Rate for Payer: Mclaren Medicaid	$32.62
Rate for Payer: Meridian Medicaid	$34.25
Rate for Payer: Opus (Opus Packaging Group) HMA	$51.75
Rate for Payer: Priority Health Choice Medicaid	$32.62
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$53.30
Rate for Payer: Priority Health Narrow/Tiered Network	$53.30
Rate for Payer: UHC Medicaid	$32.62
Rate for Payer: UHCCP Medicaid	$32.62

PR SBSQ OBSERVATION CARE/DAY 15 MINUTES

Professional

Both

$88.00

Service Code	HCPCS 99224
Min. Negotiated Rate	$35.20
Max. Negotiated Rate	$66.00
Rate for Payer: Aetna Medicare	$44.00
Rate for Payer: BCBS Complete	$35.20
Rate for Payer: Cash Price	$70.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$66.00

PR SBSQ OBSERVATION CARE/DAY 25 MINUTES

Professional

Both

$155.00

Service Code	HCPCS 99225
Min. Negotiated Rate	$62.00
Max. Negotiated Rate	$116.25
Rate for Payer: Aetna Medicare	$77.50
Rate for Payer: BCBS Complete	$62.00
Rate for Payer: Cash Price	$124.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$116.25

PR SBSQ OBSERVATION CARE/DAY 35 MINUTES

Professional

Both

$231.00

Service Code	HCPCS 99226
Min. Negotiated Rate	$92.40
Max. Negotiated Rate	$173.25
Rate for Payer: Aetna Medicare	$115.50
Rate for Payer: BCBS Complete	$92.40
Rate for Payer: Cash Price	$184.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$173.25

PR SBSQ PSYCHIATRIC COLLAB CARE MGMT 1ST 60 MINS

Professional

Both

$260.00

Service Code	HCPCS 99493
Min. Negotiated Rate	$57.08
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$101.13
Rate for Payer: Aetna Medicare	$130.00
Rate for Payer: BCBS Complete	$59.93
Rate for Payer: BCN Commercial	$98.64
Rate for Payer: Cash Price	$208.00
Rate for Payer: Cash Price	$208.00
Rate for Payer: Mclaren Medicaid	$57.08
Rate for Payer: Meridian Medicaid	$59.93
Rate for Payer: Opus (Opus Packaging Group) HMA	$195.00
Rate for Payer: Priority Health Choice Medicaid	$57.08
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$154.29
Rate for Payer: Priority Health Narrow/Tiered Network	$154.29
Rate for Payer: UHC Medicaid	$57.08
Rate for Payer: UHCCP Medicaid	$57.08

PR SCLEROTHERAPY FLUID COLLECTION PRQ W/IMG GID

Professional

Both

$2,335.00

Service Code	HCPCS 49185
Min. Negotiated Rate	$67.10
Max. Negotiated Rate	$1,751.25
Rate for Payer: Aetna Commercial	$158.18
Rate for Payer: Aetna Medicare	$1,167.50
Rate for Payer: BCBS Complete	$70.45
Rate for Payer: BCN Commercial	$176.28
Rate for Payer: Cash Price	$1,868.00
Rate for Payer: Cash Price	$1,868.00
Rate for Payer: Mclaren Medicaid	$67.10
Rate for Payer: Meridian Medicaid	$70.45
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,751.25
Rate for Payer: Priority Health Choice Medicaid	$67.10
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$214.80
Rate for Payer: Priority Health Narrow/Tiered Network	$214.80
Rate for Payer: UHC Medicaid	$67.10
Rate for Payer: UHCCP Medicaid	$67.10

PR SCREENING PAP SMEAR BY PHYS

Professional

Both

$66.00

Service Code	HCPCS P3001
Min. Negotiated Rate	$19.81
Max. Negotiated Rate	$49.50
Rate for Payer: Aetna Commercial	$19.81
Rate for Payer: Aetna Medicare	$33.00
Rate for Payer: BCBS Complete	$26.40
Rate for Payer: BCN Commercial	$37.35
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 SCREENING PROCTOSCOPY

Professional

Both

$159.00

Service Code	HCPCS S0601
Min. Negotiated Rate	$24.45
Max. Negotiated Rate	$119.25
Rate for Payer: Aetna Commercial	$24.45
Rate for Payer: Aetna Medicare	$79.50
Rate for Payer: BCBS Complete	$63.60
Rate for Payer: BCN Commercial	$67.74
Rate for Payer: Cash Price	$127.20
Rate for Payer: Cash Price	$127.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$119.25

PR SCREENING TEST PURE TONE AIR ONLY

Professional

Both

$30.00

Service Code	HCPCS 92551
Min. Negotiated Rate	$12.13
Max. Negotiated Rate	$22.50
Rate for Payer: Aetna Commercial	$12.13
Rate for Payer: Aetna Medicare	$15.00
Rate for Payer: BCN Commercial	$18.92
Rate for Payer: Cash Price	$24.00
Rate for Payer: Cash Price	$24.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$22.50
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$17.45
Rate for Payer: Priority Health Narrow/Tiered Network	$17.45

PR SCREENING TEST VISUAL ACUITY QUANTITATIVE BILAT

Professional

Both

$24.00

Service Code	HCPCS 99173
Min. Negotiated Rate	$3.23
Max. Negotiated Rate	$18.00
Rate for Payer: Aetna Commercial	$3.23
Rate for Payer: Aetna Medicare	$12.00
Rate for Payer: BCBS Complete	$9.60
Rate for Payer: BCN Commercial	$4.98
Rate for Payer: Cash Price	$19.20
Rate for Payer: Cash Price	$19.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$18.00
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$4.59
Rate for Payer: Priority Health Narrow/Tiered Network	$4.59

PR SCR MAMMO BI INCL CAD

Professional

Both

$213.00

Service Code	HCPCS G0202
Min. Negotiated Rate	$85.20
Max. Negotiated Rate	$159.75
Rate for Payer: Aetna Medicare	$106.50
Rate for Payer: BCBS Complete	$85.20
Rate for Payer: Cash Price	$170.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$159.75

PR SCROTAL EXPLORATION

Professional

Both

$723.00

Service Code	HCPCS 55110
Min. Negotiated Rate	$231.53
Max. Negotiated Rate	$640.65
Rate for Payer: Aetna Commercial	$496.07
Rate for Payer: Aetna Medicare	$361.50
Rate for Payer: BCBS Complete	$243.11
Rate for Payer: BCN Commercial	$588.12
Rate for Payer: Cash Price	$578.40
Rate for Payer: Cash Price	$578.40
Rate for Payer: Mclaren Medicaid	$231.53
Rate for Payer: Meridian Medicaid	$243.11
Rate for Payer: Opus (Opus Packaging Group) HMA	$542.25
Rate for Payer: Priority Health Choice Medicaid	$231.53
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$640.65
Rate for Payer: Priority Health Narrow/Tiered Network	$640.65
Rate for Payer: UHC Medicaid	$231.53
Rate for Payer: UHCCP Medicaid	$231.53

PR SCROTOPLASTY COMPLICATED

Professional

Both

$1,456.00

Service Code	HCPCS 55180
Min. Negotiated Rate	$397.88
Max. Negotiated Rate	$1,126.70
Rate for Payer: Aetna Commercial	$887.31
Rate for Payer: Aetna Medicare	$728.00
Rate for Payer: BCBS Complete	$417.77
Rate for Payer: BCN Commercial	$1,034.31
Rate for Payer: Cash Price	$1,164.80
Rate for Payer: Cash Price	$1,164.80
Rate for Payer: Mclaren Medicaid	$397.88
Rate for Payer: Meridian Medicaid	$417.77
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,092.00
Rate for Payer: Priority Health Choice Medicaid	$397.88
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$1,126.70
Rate for Payer: Priority Health Narrow/Tiered Network	$1,126.70
Rate for Payer: UHC Medicaid	$397.88
Rate for Payer: UHCCP Medicaid	$397.88

PR SCROTOPLASTY SIMPLE

Professional

Both

$705.00

Service Code	HCPCS 55175
Min. Negotiated Rate	$216.62
Max. Negotiated Rate	$601.59
Rate for Payer: Aetna Commercial	$466.37
Rate for Payer: Aetna Medicare	$352.50
Rate for Payer: BCBS Complete	$227.45
Rate for Payer: BCN Commercial	$552.26
Rate for Payer: Cash Price	$564.00
Rate for Payer: Cash Price	$564.00
Rate for Payer: Mclaren Medicaid	$216.62
Rate for Payer: Meridian Medicaid	$227.45
Rate for Payer: Opus (Opus Packaging Group) HMA	$528.75
Rate for Payer: Priority Health Choice Medicaid	$216.62
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$601.59
Rate for Payer: Priority Health Narrow/Tiered Network	$601.59
Rate for Payer: UHC Medicaid	$216.62
Rate for Payer: UHCCP Medicaid	$216.62

PR SEC ABDOMINAL WALL SUTURE EVISCERATION/DEHSN

Professional

Both

$2,416.00

Service Code	HCPCS 49900
Min. Negotiated Rate	$510.35
Max. Negotiated Rate	$1,812.00
Rate for Payer: Aetna Commercial	$1,096.92
Rate for Payer: Aetna Medicare	$1,208.00
Rate for Payer: BCBS Complete	$535.87
Rate for Payer: BCN Commercial	$1,247.94
Rate for Payer: Cash Price	$1,932.80
Rate for Payer: Cash Price	$1,932.80
Rate for Payer: Mclaren Medicaid	$510.35
Rate for Payer: Meridian Medicaid	$535.87
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,812.00
Rate for Payer: Priority Health Choice Medicaid	$510.35
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$1,520.53
Rate for Payer: Priority Health Narrow/Tiered Network	$1,520.53
Rate for Payer: UHC Medicaid	$510.35
Rate for Payer: UHCCP Medicaid	$510.35

Know your out-of-pocket cost for care.

All Charges