Bronson Lakeview Hospital

All Charges

Charge

Type

Setting

Price

PR STRTCTC CPTR ASSTD PX EXTRADURAL CRANIAL

Professional

Both

$765.00

Service Code	HCPCS 61782
Min. Negotiated Rate	$92.02
Max. Negotiated Rate	$573.75
Rate for Payer: Aetna Commercial	$222.50
Rate for Payer: Aetna Medicare	$382.50
Rate for Payer: BCBS Complete	$96.62
Rate for Payer: BCN Commercial	$257.45
Rate for Payer: Cash Price	$612.00
Rate for Payer: Cash Price	$612.00
Rate for Payer: Mclaren Medicaid	$92.02
Rate for Payer: Meridian Medicaid	$96.62
Rate for Payer: Opus (Opus Packaging Group) HMA	$573.75
Rate for Payer: Priority Health Choice Medicaid	$92.02
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$299.03
Rate for Payer: Priority Health Narrow/Tiered Network	$299.03
Rate for Payer: UHC Medicaid	$92.02
Rate for Payer: UHCCP Medicaid	$92.02

PR STRTCTC RADIOSURGERY EA ADDL CRANIAL LES COMPLEX

Professional

Both

$8,565.00

Service Code	HCPCS 61799
Min. Negotiated Rate	$175.73
Max. Negotiated Rate	$6,423.75
Rate for Payer: Aetna Commercial	$391.39
Rate for Payer: Aetna Medicare	$4,282.50
Rate for Payer: BCBS Complete	$184.52
Rate for Payer: BCN Commercial	$454.16
Rate for Payer: Cash Price	$6,852.00
Rate for Payer: Cash Price	$6,852.00
Rate for Payer: Mclaren Medicaid	$175.73
Rate for Payer: Meridian Medicaid	$184.52
Rate for Payer: Opus (Opus Packaging Group) HMA	$6,423.75
Rate for Payer: Priority Health Choice Medicaid	$175.73
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$527.50
Rate for Payer: Priority Health Narrow/Tiered Network	$527.50
Rate for Payer: UHC Medicaid	$175.73
Rate for Payer: UHCCP Medicaid	$175.73

PR STRTCTC RADIOSURGERY EA ADDL CRANIAL LES SIMPLE

Professional

Both

$8,565.00

Service Code	HCPCS 61797
Min. Negotiated Rate	$127.59
Max. Negotiated Rate	$6,423.75
Rate for Payer: Aetna Commercial	$284.57
Rate for Payer: Aetna Medicare	$4,282.50
Rate for Payer: BCBS Complete	$133.97
Rate for Payer: BCN Commercial	$329.17
Rate for Payer: Cash Price	$6,852.00
Rate for Payer: Cash Price	$6,852.00
Rate for Payer: Mclaren Medicaid	$127.59
Rate for Payer: Meridian Medicaid	$133.97
Rate for Payer: Opus (Opus Packaging Group) HMA	$6,423.75
Rate for Payer: Priority Health Choice Medicaid	$127.59
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$382.32
Rate for Payer: Priority Health Narrow/Tiered Network	$382.32
Rate for Payer: UHC Medicaid	$127.59
Rate for Payer: UHCCP Medicaid	$127.59

PR SUBCUTANEOUS HORMONE PELLET IMPLANTATION

Professional

Both

$187.00

Service Code	HCPCS 11980
Min. Negotiated Rate	$30.89
Max. Negotiated Rate	$140.25
Rate for Payer: Aetna Commercial	$61.12
Rate for Payer: Aetna Medicare	$93.50
Rate for Payer: BCBS Complete	$32.43
Rate for Payer: BCN Commercial	$82.17
Rate for Payer: Cash Price	$149.60
Rate for Payer: Cash Price	$149.60
Rate for Payer: Mclaren Medicaid	$30.89
Rate for Payer: Meridian Medicaid	$32.43
Rate for Payer: Opus (Opus Packaging Group) HMA	$140.25
Rate for Payer: Priority Health Choice Medicaid	$30.89
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$75.20
Rate for Payer: Priority Health Narrow/Tiered Network	$75.20
Rate for Payer: UHC Medicaid	$30.89
Rate for Payer: UHCCP Medicaid	$30.89

PR SUBDURAL TAP FONTANELLE/SUTUR INFANT UNI/BI INIT

Professional

Both

$480.00

Service Code	HCPCS 61000
Min. Negotiated Rate	$70.93
Max. Negotiated Rate	$360.00
Rate for Payer: Aetna Commercial	$145.81
Rate for Payer: Aetna Medicare	$240.00
Rate for Payer: BCBS Complete	$74.48
Rate for Payer: BCN Commercial	$238.72
Rate for Payer: Cash Price	$384.00
Rate for Payer: Cash Price	$384.00
Rate for Payer: Mclaren Medicaid	$70.93
Rate for Payer: Meridian Medicaid	$74.48
Rate for Payer: Opus (Opus Packaging Group) HMA	$360.00
Rate for Payer: Priority Health Choice Medicaid	$70.93
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$200.70
Rate for Payer: Priority Health Narrow/Tiered Network	$200.70
Rate for Payer: UHC Medicaid	$70.93
Rate for Payer: UHCCP Medicaid	$70.93

PR SUB GRFT F/S/N/H/F/G/M/D >= 100SCM 1ST 100SQ CM

Professional

Both

$506.00

Service Code	HCPCS 15277
Min. Negotiated Rate	$125.88
Max. Negotiated Rate	$379.50
Rate for Payer: Aetna Commercial	$245.92
Rate for Payer: Aetna Medicare	$253.00
Rate for Payer: BCBS Complete	$132.17
Rate for Payer: BCN Commercial	$332.15
Rate for Payer: Cash Price	$404.80
Rate for Payer: Cash Price	$404.80
Rate for Payer: Mclaren Medicaid	$125.88
Rate for Payer: Meridian Medicaid	$132.17
Rate for Payer: Opus (Opus Packaging Group) HMA	$379.50
Rate for Payer: Priority Health Choice Medicaid	$125.88
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$304.00
Rate for Payer: Priority Health Narrow/Tiered Network	$304.00
Rate for Payer: UHC Medicaid	$125.88
Rate for Payer: UHCCP Medicaid	$125.88

PR SUB GRFT F/S/N/H/F/G/M/D >= 100SCM ADL 100SQ CM

Professional

Both

$133.00

Service Code	HCPCS 15278
Min. Negotiated Rate	$31.10
Max. Negotiated Rate	$99.75
Rate for Payer: Aetna Commercial	$61.98
Rate for Payer: Aetna Medicare	$66.50
Rate for Payer: BCBS Complete	$32.66
Rate for Payer: BCN Commercial	$83.16
Rate for Payer: Cash Price	$106.40
Rate for Payer: Cash Price	$106.40
Rate for Payer: Mclaren Medicaid	$31.10
Rate for Payer: Meridian Medicaid	$32.66
Rate for Payer: Opus (Opus Packaging Group) HMA	$99.75
Rate for Payer: Priority Health Choice Medicaid	$31.10
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$76.12
Rate for Payer: Priority Health Narrow/Tiered Network	$76.12
Rate for Payer: UHC Medicaid	$31.10
Rate for Payer: UHCCP Medicaid	$31.10

PR SUB GRFT F/S/N/H/F/G/M/D <100SQ CM 1ST 25 SQ CM

Professional

Both

$291.00

Service Code	HCPCS 15275
Min. Negotiated Rate	$53.68
Max. Negotiated Rate	$218.25
Rate for Payer: Aetna Commercial	$102.56
Rate for Payer: Aetna Medicare	$145.50
Rate for Payer: BCBS Complete	$56.36
Rate for Payer: BCN Commercial	$139.44
Rate for Payer: Cash Price	$232.80
Rate for Payer: Cash Price	$232.80
Rate for Payer: Mclaren Medicaid	$53.68
Rate for Payer: Meridian Medicaid	$56.36
Rate for Payer: Opus (Opus Packaging Group) HMA	$218.25
Rate for Payer: Priority Health Choice Medicaid	$53.68
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$127.62
Rate for Payer: Priority Health Narrow/Tiered Network	$127.62
Rate for Payer: UHC Medicaid	$53.68
Rate for Payer: UHCCP Medicaid	$53.68

PR SUB GRFT F/S/N/H/F/G/M/D<100SQ CM EA ADDL25SQ CM

Professional

Both

$68.00

Service Code	HCPCS 15276
Min. Negotiated Rate	$14.06
Max. Negotiated Rate	$51.00
Rate for Payer: Aetna Commercial	$27.39
Rate for Payer: Aetna Medicare	$34.00
Rate for Payer: BCBS Complete	$14.76
Rate for Payer: BCN Commercial	$36.85
Rate for Payer: Cash Price	$54.40
Rate for Payer: Cash Price	$54.40
Rate for Payer: Mclaren Medicaid	$14.06
Rate for Payer: Meridian Medicaid	$14.76
Rate for Payer: Opus (Opus Packaging Group) HMA	$51.00
Rate for Payer: Priority Health Choice Medicaid	$14.06
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$33.73
Rate for Payer: Priority Health Narrow/Tiered Network	$33.73
Rate for Payer: UHC Medicaid	$14.06
Rate for Payer: UHCCP Medicaid	$14.06

PR SUBMUCOSAL ABLTJ TONGUE RF 1/> SITES PR SESSION

Professional

Both

$756.00

Service Code	HCPCS 41530
Min. Negotiated Rate	$230.68
Max. Negotiated Rate	$689.28
Rate for Payer: Aetna Commercial	$504.96
Rate for Payer: Aetna Medicare	$378.00
Rate for Payer: BCBS Complete	$242.21
Rate for Payer: BCN Commercial	$565.70
Rate for Payer: Cash Price	$604.80
Rate for Payer: Cash Price	$604.80
Rate for Payer: Mclaren Medicaid	$230.68
Rate for Payer: Meridian Medicaid	$242.21
Rate for Payer: Opus (Opus Packaging Group) HMA	$567.00
Rate for Payer: Priority Health Choice Medicaid	$230.68
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$689.28
Rate for Payer: Priority Health Narrow/Tiered Network	$689.28
Rate for Payer: UHC Medicaid	$230.68
Rate for Payer: UHCCP Medicaid	$230.68

PR SUBMUCOUS RESCJ INFERIOR TURBINATE PRTL/COMPL

Professional

Both

$1,179.00

Service Code	HCPCS 30140
Min. Negotiated Rate	$97.77
Max. Negotiated Rate	$884.25
Rate for Payer: Aetna Commercial	$227.50
Rate for Payer: Aetna Medicare	$589.50
Rate for Payer: BCBS Complete	$102.66
Rate for Payer: BCN Commercial	$267.42
Rate for Payer: Cash Price	$943.20
Rate for Payer: Cash Price	$943.20
Rate for Payer: Mclaren Medicaid	$97.77
Rate for Payer: Meridian Medicaid	$102.66
Rate for Payer: Opus (Opus Packaging Group) HMA	$884.25
Rate for Payer: Priority Health Choice Medicaid	$97.77
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$251.83
Rate for Payer: Priority Health Narrow/Tiered Network	$251.83
Rate for Payer: UHC Medicaid	$97.77
Rate for Payer: UHCCP Medicaid	$97.77

PR SUBQ HOSPITAL CARE PER DAY E/M NORMAL NEWBORN

Professional

Both

$163.00

Service Code	HCPCS 99462
Min. Negotiated Rate	$22.58
Max. Negotiated Rate	$122.25
Rate for Payer: Aetna Commercial	$40.96
Rate for Payer: Aetna Medicare	$81.50
Rate for Payer: BCBS Complete	$23.71
Rate for Payer: BCN Commercial	$59.26
Rate for Payer: Cash Price	$130.40
Rate for Payer: Cash Price	$130.40
Rate for Payer: Mclaren Medicaid	$22.58
Rate for Payer: Meridian Medicaid	$23.71
Rate for Payer: Opus (Opus Packaging Group) HMA	$122.25
Rate for Payer: Priority Health Choice Medicaid	$22.58
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	$22.58
Rate for Payer: UHCCP Medicaid	$22.58

PR SUBQ I/P CRITICAL CARE PR DAY AGE 28 DAYS/<

Professional

Both

$817.00

Service Code	HCPCS 99469
Min. Negotiated Rate	$334.07
Max. Negotiated Rate	$612.75
Rate for Payer: Aetna Commercial	$390.36
Rate for Payer: Aetna Medicare	$408.50
Rate for Payer: BCBS Complete	$350.77
Rate for Payer: BCN Commercial	$568.20
Rate for Payer: Cash Price	$653.60
Rate for Payer: Cash Price	$653.60
Rate for Payer: Mclaren Medicaid	$334.07
Rate for Payer: Meridian Medicaid	$350.77
Rate for Payer: Opus (Opus Packaging Group) HMA	$612.75
Rate for Payer: Priority Health Choice Medicaid	$334.07
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$598.52
Rate for Payer: Priority Health Narrow/Tiered Network	$598.52
Rate for Payer: UHC Medicaid	$334.07
Rate for Payer: UHCCP Medicaid	$334.07

PR SUBSEQUENT INJECTION, PLATELET RICH PLASMA, ANY SITE, INCLUDING IMAGE GUIDANCE, HARVESTING AND PREPARATION WHEN PERFORMED

Professional

Both

$315.00

Hospital Revenue Code	990
Min. Negotiated Rate	$126.00
Max. Negotiated Rate	$236.25
Rate for Payer: Aetna Medicare	$157.50
Rate for Payer: BCBS Complete	$126.00
Rate for Payer: Cash Price	$252.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$236.25

PR SUBSEQUENT PED CRITICAL CARE 2 THRU 5 YEARS

Professional

Both

$966.00

Service Code	HCPCS 99476
Min. Negotiated Rate	$302.92
Max. Negotiated Rate	$724.50
Rate for Payer: Aetna Commercial	$338.56
Rate for Payer: Aetna Medicare	$483.00
Rate for Payer: BCBS Complete	$318.07
Rate for Payer: BCN Commercial	$500.97
Rate for Payer: Cash Price	$772.80
Rate for Payer: Cash Price	$772.80
Rate for Payer: Mclaren Medicaid	$302.92
Rate for Payer: Meridian Medicaid	$318.07
Rate for Payer: Opus (Opus Packaging Group) HMA	$724.50
Rate for Payer: Priority Health Choice Medicaid	$302.92
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$450.63
Rate for Payer: Priority Health Narrow/Tiered Network	$450.63
Rate for Payer: UHC Medicaid	$302.92
Rate for Payer: UHCCP Medicaid	$302.92

PR SUBSQ PED CRITICAL CARE 29 DAYS THRU 24 MO

Professional

Both

$745.00

Service Code	HCPCS 99472
Min. Negotiated Rate	$348.52
Max. Negotiated Rate	$619.98
Rate for Payer: Aetna Commercial	$397.47
Rate for Payer: Aetna Medicare	$372.50
Rate for Payer: BCBS Complete	$365.95
Rate for Payer: BCN Commercial	$590.60
Rate for Payer: Cash Price	$596.00
Rate for Payer: Cash Price	$596.00
Rate for Payer: Mclaren Medicaid	$348.52
Rate for Payer: Meridian Medicaid	$365.95
Rate for Payer: Opus (Opus Packaging Group) HMA	$558.75
Rate for Payer: Priority Health Choice Medicaid	$348.52
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$619.98
Rate for Payer: Priority Health Narrow/Tiered Network	$619.98
Rate for Payer: UHC Medicaid	$348.52
Rate for Payer: UHCCP Medicaid	$348.52

PR SUBTEMPORAL CRANIAL DECOMPRESSION

Professional

Both

$4,363.00

Service Code	HCPCS 61340
Min. Negotiated Rate	$910.58
Max. Negotiated Rate	$3,272.25
Rate for Payer: Aetna Commercial	$1,861.73
Rate for Payer: Aetna Medicare	$2,181.50
Rate for Payer: BCBS Complete	$956.11
Rate for Payer: BCN Commercial	$3,041.53
Rate for Payer: Cash Price	$3,490.40
Rate for Payer: Cash Price	$3,490.40
Rate for Payer: Mclaren Medicaid	$910.58
Rate for Payer: Meridian Medicaid	$956.11
Rate for Payer: Opus (Opus Packaging Group) HMA	$3,272.25
Rate for Payer: Priority Health Choice Medicaid	$910.58
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$2,557.09
Rate for Payer: Priority Health Narrow/Tiered Network	$2,557.09
Rate for Payer: UHC Medicaid	$910.58
Rate for Payer: UHCCP Medicaid	$910.58

PR SUCTION ASSISTED LIPECTOMY HEAD & NECK

Professional

Both

$2,101.00

Service Code	HCPCS 15876
Min. Negotiated Rate	$217.36
Max. Negotiated Rate	$1,575.75
Rate for Payer: Aetna Commercial	$367.50
Rate for Payer: Aetna Medicare	$1,050.50
Rate for Payer: BCBS Complete	$488.01
Rate for Payer: BCN Commercial	$878.21
Rate for Payer: Cash Price	$1,680.80
Rate for Payer: Cash Price	$1,680.80
Rate for Payer: Mclaren Medicaid	$464.77
Rate for Payer: Meridian Medicaid	$488.01
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,575.75
Rate for Payer: Priority Health Choice Medicaid	$464.77
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$217.36
Rate for Payer: Priority Health Narrow/Tiered Network	$217.36
Rate for Payer: UHC Medicaid	$464.77
Rate for Payer: UHCCP Medicaid	$464.77

PR SUCTION ASSISTED LIPECTOMY LOWER EXTREMITY

Professional

Both

$3,257.00

Service Code	HCPCS 15879
Min. Negotiated Rate	$217.36
Max. Negotiated Rate	$2,442.75
Rate for Payer: Aetna Commercial	$656.25
Rate for Payer: Aetna Medicare	$1,628.50
Rate for Payer: BCBS Complete	$1,302.80
Rate for Payer: BCN Commercial	$900.16
Rate for Payer: Cash Price	$2,605.60
Rate for Payer: Cash Price	$2,605.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$2,442.75
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$217.36
Rate for Payer: Priority Health Narrow/Tiered Network	$217.36

PR SUCTION ASSISTED LIPECTOMY TRUNK

Professional

Both

$2,837.00

Service Code	HCPCS 15877
Min. Negotiated Rate	$217.36
Max. Negotiated Rate	$2,127.75
Rate for Payer: Aetna Commercial	$656.25
Rate for Payer: Aetna Medicare	$1,418.50
Rate for Payer: BCBS Complete	$1,134.80
Rate for Payer: BCN Commercial	$878.21
Rate for Payer: Cash Price	$2,269.60
Rate for Payer: Cash Price	$2,269.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$2,127.75
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$217.36
Rate for Payer: Priority Health Narrow/Tiered Network	$217.36

PR SUMATRIPTAN SUCCINATE / 6 MG

Professional

Both

$115.00

Service Code	HCPCS J3030
Min. Negotiated Rate	$2.09
Max. Negotiated Rate	$86.25
Rate for Payer: Aetna Commercial	$60.24
Rate for Payer: Aetna Medicare	$57.50
Rate for Payer: BCBS Trust/PPO	$2.09
Rate for Payer: BCN Commercial	$2.10
Rate for Payer: Cash Price	$92.00
Rate for Payer: Cash Price	$92.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$86.25

PR SUPERVISION HOSPICE PATIENT/MONTH 15-29 MIN

Professional

Both

$140.00

Service Code	HCPCS 99377
Min. Negotiated Rate	$55.68
Max. Negotiated Rate	$105.00
Rate for Payer: Aetna Commercial	$55.68
Rate for Payer: Aetna Medicare	$70.00
Rate for Payer: BCBS Complete	$56.00
Rate for Payer: BCN Commercial	$79.18
Rate for Payer: Cash Price	$112.00
Rate for Payer: Cash Price	$112.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$105.00
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$71.22
Rate for Payer: Priority Health Narrow/Tiered Network	$71.22

PR SUPERVISION INTERFACILITY TRANSPORT INIT 30 MIN

Professional

Both

$158.00

Service Code	HCPCS 99485
Min. Negotiated Rate	$63.20
Max. Negotiated Rate	$118.50
Rate for Payer: Aetna Commercial	$75.97
Rate for Payer: Aetna Medicare	$79.00
Rate for Payer: BCBS Complete	$63.20
Rate for Payer: BCN Commercial	$108.06
Rate for Payer: Cash Price	$126.40
Rate for Payer: Cash Price	$126.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$118.50
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$97.20
Rate for Payer: Priority Health Narrow/Tiered Network	$97.20

PR SUPERVISION NURS FACILITY PATIENT MO 15-29 MIN

Professional

Both

$140.00

Service Code	HCPCS 99379
Min. Negotiated Rate	$55.68
Max. Negotiated Rate	$105.00
Rate for Payer: Aetna Commercial	$55.68
Rate for Payer: Aetna Medicare	$70.00
Rate for Payer: BCBS Complete	$56.00
Rate for Payer: BCN Commercial	$79.18
Rate for Payer: Cash Price	$112.00
Rate for Payer: Cash Price	$112.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$105.00
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$71.22
Rate for Payer: Priority Health Narrow/Tiered Network	$71.22

PR SUPERVISION NURS FACILITY PATIENT MONTH 30 MIN/>

Professional

Both

$178.00

Service Code	HCPCS 99380
Min. Negotiated Rate	$71.20
Max. Negotiated Rate	$133.50
Rate for Payer: Aetna Commercial	$87.31
Rate for Payer: Aetna Medicare	$89.00
Rate for Payer: BCBS Complete	$71.20
Rate for Payer: BCN Commercial	$125.99
Rate for Payer: Cash Price	$142.40
Rate for Payer: Cash Price	$142.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$133.50
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$113.34
Rate for Payer: Priority Health Narrow/Tiered Network	$113.34

Know your out-of-pocket cost for care.

All Charges