Bronson Lakeview Hospital

All Charges

Charge

Type

Setting

Price

PR TC99M DISOFENIN

Professional

Both

$263.00

Service Code	HCPCS A9510
Min. Negotiated Rate	$60.00
Max. Negotiated Rate	$197.25
Rate for Payer: Aetna Commercial	$67.20
Rate for Payer: Aetna Medicare	$131.50
Rate for Payer: BCN Commercial	$60.00
Rate for Payer: Cash Price	$210.40
Rate for Payer: Cash Price	$210.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$197.25

PR TC99M MEBROFENIN

Professional

Both

$250.00

Service Code	HCPCS A9537
Min. Negotiated Rate	$53.10
Max. Negotiated Rate	$187.50
Rate for Payer: Aetna Commercial	$53.10
Rate for Payer: Aetna Medicare	$125.00
Rate for Payer: BCN Commercial	$69.79
Rate for Payer: Cash Price	$200.00
Rate for Payer: Cash Price	$200.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$187.50

PR TC99M MEDRONATE

Professional

Both

$95.00

Service Code	HCPCS A9503
Min. Negotiated Rate	$12.48
Max. Negotiated Rate	$71.25
Rate for Payer: Aetna Commercial	$12.48
Rate for Payer: Aetna Medicare	$47.50
Rate for Payer: BCN Commercial	$35.00
Rate for Payer: Cash Price	$76.00
Rate for Payer: Cash Price	$76.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$71.25

PR TC99M PERTECHNETATE

Professional

Both

$21.00

Service Code	HCPCS A9512
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$15.75
Rate for Payer: Aetna Commercial	$1.50
Rate for Payer: Aetna Medicare	$10.50
Rate for Payer: BCN Commercial	$3.00
Rate for Payer: Cash Price	$16.80
Rate for Payer: Cash Price	$16.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$15.75

PR TC99M SESTAMIBI

Professional

Both

$330.00

Service Code	HCPCS A9500
Min. Negotiated Rate	$102.48
Max. Negotiated Rate	$247.50
Rate for Payer: Aetna Commercial	$102.48
Rate for Payer: Aetna Medicare	$165.00
Rate for Payer: BCN Commercial	$128.10
Rate for Payer: Cash Price	$264.00
Rate for Payer: Cash Price	$264.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$247.50

PR TCATH STENT PLACEMT ANTEGRADE CAROTID/INNOMINATE

Professional

Both

$1,868.00

Service Code	HCPCS 37218
Min. Negotiated Rate	$473.07
Max. Negotiated Rate	$1,401.00
Rate for Payer: Aetna Commercial	$1,098.34
Rate for Payer: Aetna Medicare	$934.00
Rate for Payer: BCBS Complete	$496.72
Rate for Payer: BCN Commercial	$1,216.57
Rate for Payer: Cash Price	$1,494.40
Rate for Payer: Cash Price	$1,494.40
Rate for Payer: Mclaren Medicaid	$473.07
Rate for Payer: Meridian Medicaid	$496.72
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,401.00
Rate for Payer: Priority Health Choice Medicaid	$473.07
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$1,308.26
Rate for Payer: Priority Health Narrow/Tiered Network	$1,308.26
Rate for Payer: UHC Medicaid	$473.07
Rate for Payer: UHCCP Medicaid	$473.07

PR TCATH STENT PLACEMT RETROGRAD CAROTID/INNOMINATE

Professional

Both

$1,808.00

Service Code	HCPCS 37217
Min. Negotiated Rate	$624.52
Max. Negotiated Rate	$1,702.94
Rate for Payer: Aetna Commercial	$1,445.26
Rate for Payer: Aetna Medicare	$904.00
Rate for Payer: BCBS Complete	$655.75
Rate for Payer: BCN Commercial	$1,583.58
Rate for Payer: Cash Price	$1,446.40
Rate for Payer: Cash Price	$1,446.40
Rate for Payer: Mclaren Medicaid	$624.52
Rate for Payer: Meridian Medicaid	$655.75
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,356.00
Rate for Payer: Priority Health Choice Medicaid	$624.52
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$1,702.94
Rate for Payer: Priority Health Narrow/Tiered Network	$1,702.94
Rate for Payer: UHC Medicaid	$624.52
Rate for Payer: UHCCP Medicaid	$624.52

PR TCAT IMPL WRLS P-ART PRS SNR L-T HEMODYN MNTR

Professional

Both

$708.00

Service Code	HCPCS 33289
Min. Negotiated Rate	$181.26
Max. Negotiated Rate	$531.00
Rate for Payer: Aetna Commercial	$447.42
Rate for Payer: Aetna Medicare	$354.00
Rate for Payer: BCBS Complete	$190.32
Rate for Payer: BCN Commercial	$489.52
Rate for Payer: Cash Price	$566.40
Rate for Payer: Cash Price	$566.40
Rate for Payer: Mclaren Medicaid	$181.26
Rate for Payer: Meridian Medicaid	$190.32
Rate for Payer: Opus (Opus Packaging Group) HMA	$531.00
Rate for Payer: Priority Health Choice Medicaid	$181.26
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$526.42
Rate for Payer: Priority Health Narrow/Tiered Network	$526.42
Rate for Payer: UHC Medicaid	$181.26
Rate for Payer: UHCCP Medicaid	$181.26

PR TCAT INSJ PERM 1CHMBR LDLS PACEMAKER R ATRIAL

Professional

Both

$787.00

Service Code	HCPCS 0823T
Min. Negotiated Rate	$314.80
Max. Negotiated Rate	$17,831.53
Rate for Payer: Aetna Medicare	$393.50
Rate for Payer: BCBS Complete	$314.80
Rate for Payer: BCN Commercial	$17,831.53
Rate for Payer: Cash Price	$629.60
Rate for Payer: Cash Price	$629.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$590.25
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$645.32
Rate for Payer: Priority Health Narrow/Tiered Network	$645.32

PR TCAT INSJ PERM DUAL CHAMBER LDLS PM COMPL SYS

Professional

Both

$25,536.00

Service Code	HCPCS 0795T
Min. Negotiated Rate	$10,214.40
Max. Negotiated Rate	$19,152.00
Rate for Payer: Aetna Medicare	$12,768.00
Rate for Payer: BCBS Complete	$10,214.40
Rate for Payer: BCN Commercial	$17,831.53
Rate for Payer: Cash Price	$20,428.80
Rate for Payer: Cash Price	$20,428.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$19,152.00

PR TCAT INSJ/RPL PERM LEADLESS PACEMAKER RV W/IMG

Professional

Both

$1,051.00

Service Code	HCPCS 33274
Min. Negotiated Rate	$267.53
Max. Negotiated Rate	$788.25
Rate for Payer: Aetna Commercial	$648.93
Rate for Payer: Aetna Medicare	$525.50
Rate for Payer: BCBS Complete	$280.91
Rate for Payer: BCN Commercial	$702.65
Rate for Payer: Cash Price	$840.80
Rate for Payer: Cash Price	$840.80
Rate for Payer: Mclaren Medicaid	$267.53
Rate for Payer: Meridian Medicaid	$280.91
Rate for Payer: Opus (Opus Packaging Group) HMA	$788.25
Rate for Payer: Priority Health Choice Medicaid	$267.53
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$755.61
Rate for Payer: Priority Health Narrow/Tiered Network	$755.61
Rate for Payer: UHC Medicaid	$267.53
Rate for Payer: UHCCP Medicaid	$267.53

PR TCAT IV STENT CRV CRTD ART EMBOLIC PROTECJ

Professional

Both

$2,173.00

Service Code	HCPCS 37215
Min. Negotiated Rate	$567.22
Max. Negotiated Rate	$1,629.75
Rate for Payer: Aetna Commercial	$1,335.45
Rate for Payer: Aetna Medicare	$1,086.50
Rate for Payer: BCBS Complete	$595.58
Rate for Payer: BCN Commercial	$1,444.64
Rate for Payer: Cash Price	$1,738.40
Rate for Payer: Cash Price	$1,738.40
Rate for Payer: Mclaren Medicaid	$567.22
Rate for Payer: Meridian Medicaid	$595.58
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,629.75
Rate for Payer: Priority Health Choice Medicaid	$567.22
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$1,553.53
Rate for Payer: Priority Health Narrow/Tiered Network	$1,553.53
Rate for Payer: UHC Medicaid	$567.22
Rate for Payer: UHCCP Medicaid	$567.22

PR TCAT IV STENT CRV CRTD ART W/O EMBOLIC PROTECJ

Professional

Both

$4,310.00

Service Code	HCPCS 37216
Min. Negotiated Rate	$1,302.62
Max. Negotiated Rate	$3,232.50
Rate for Payer: Aetna Commercial	$1,302.62
Rate for Payer: Aetna Medicare	$2,155.00
Rate for Payer: BCBS Complete	$1,724.00
Rate for Payer: BCN Commercial	$1,458.09
Rate for Payer: Cash Price	$3,448.00
Rate for Payer: Cash Price	$3,448.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$3,232.50
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$1,568.00
Rate for Payer: Priority Health Narrow/Tiered Network	$1,568.00

PR TCAT MITRAL VALVE REPAIR INITIAL PROSTHESIS

Professional

Both

$3,872.00

Service Code	HCPCS 33418
Min. Negotiated Rate	$1,008.13
Max. Negotiated Rate	$2,904.00
Rate for Payer: Aetna Commercial	$2,411.52
Rate for Payer: Aetna Medicare	$1,936.00
Rate for Payer: BCBS Complete	$1,058.54
Rate for Payer: BCN Commercial	$2,635.81
Rate for Payer: Cash Price	$3,097.60
Rate for Payer: Cash Price	$3,097.60
Rate for Payer: Mclaren Medicaid	$1,008.13
Rate for Payer: Meridian Medicaid	$1,058.54
Rate for Payer: Opus (Opus Packaging Group) HMA	$2,904.00
Rate for Payer: Priority Health Choice Medicaid	$1,008.13
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$2,834.48
Rate for Payer: Priority Health Narrow/Tiered Network	$2,834.48
Rate for Payer: UHC Medicaid	$1,008.13
Rate for Payer: UHCCP Medicaid	$1,008.13

PR TCAT PERM OCCLS/EMBOLIZATION PERQ CNS

Professional

Both

$4,763.00

Service Code	HCPCS 61624
Min. Negotiated Rate	$666.26
Max. Negotiated Rate	$3,572.25
Rate for Payer: Aetna Commercial	$1,488.12
Rate for Payer: Aetna Medicare	$2,381.50
Rate for Payer: BCBS Complete	$699.57
Rate for Payer: BCN Commercial	$2,407.21
Rate for Payer: Cash Price	$3,810.40
Rate for Payer: Cash Price	$3,810.40
Rate for Payer: Mclaren Medicaid	$666.26
Rate for Payer: Meridian Medicaid	$699.57
Rate for Payer: Opus (Opus Packaging Group) HMA	$3,572.25
Rate for Payer: Priority Health Choice Medicaid	$666.26
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$2,023.80
Rate for Payer: Priority Health Narrow/Tiered Network	$2,023.80
Rate for Payer: UHC Medicaid	$666.26
Rate for Payer: UHCCP Medicaid	$666.26

PR TCAT PERM OCCLS/EMBOLJ PERQ NON-CNS HEAD/NECK

Professional

Both

$1,904.00

Service Code	HCPCS 61626
Min. Negotiated Rate	$480.95
Max. Negotiated Rate	$1,569.76
Rate for Payer: Aetna Commercial	$1,145.58
Rate for Payer: Aetna Medicare	$952.00
Rate for Payer: BCBS Complete	$505.00
Rate for Payer: BCN Commercial	$1,351.52
Rate for Payer: Cash Price	$1,523.20
Rate for Payer: Cash Price	$1,523.20
Rate for Payer: Mclaren Medicaid	$480.95
Rate for Payer: Meridian Medicaid	$505.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,428.00
Rate for Payer: Priority Health Choice Medicaid	$480.95
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$1,569.76
Rate for Payer: Priority Health Narrow/Tiered Network	$1,569.76
Rate for Payer: UHC Medicaid	$480.95
Rate for Payer: UHCCP Medicaid	$480.95

PR TCAT PLMT IV STENT ICRA W/BALO ANGIOP IF PFRMD

Professional

Both

$6,997.00

Service Code	HCPCS 61635
Min. Negotiated Rate	$1,871.57
Max. Negotiated Rate	$5,247.75
Rate for Payer: Aetna Commercial	$1,871.57
Rate for Payer: Aetna Medicare	$3,498.50
Rate for Payer: BCBS Complete	$2,798.80
Rate for Payer: BCN Commercial	$2,241.41
Rate for Payer: Cash Price	$5,597.60
Rate for Payer: Cash Price	$5,597.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$5,247.75
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$2,603.37
Rate for Payer: Priority Health Narrow/Tiered Network	$2,603.37

PR TCAT PLMT XTRC VRT CRTD STENT RS&I PRQ 1ST VSL

Professional

Both

$10,169.00

Service Code	HCPCS 0075T
Min. Negotiated Rate	$1,381.29
Max. Negotiated Rate	$7,626.75
Rate for Payer: Aetna Commercial	$1,381.29
Rate for Payer: Aetna Medicare	$5,084.50
Rate for Payer: BCBS Complete	$4,067.60
Rate for Payer: BCN Commercial	$6,509.92
Rate for Payer: Cash Price	$8,135.20
Rate for Payer: Cash Price	$8,135.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$7,626.75
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$5,900.00
Rate for Payer: Priority Health Narrow/Tiered Network	$5,900.00

PR TCAT REMOVAL PERM LEADLESS PM RIGHT VENTR W/IMG

Professional

Both

$1,781.00

Service Code	HCPCS 33275
Min. Negotiated Rate	$285.21
Max. Negotiated Rate	$1,335.75
Rate for Payer: Aetna Commercial	$704.22
Rate for Payer: Aetna Medicare	$890.50
Rate for Payer: BCBS Complete	$299.47
Rate for Payer: BCN Commercial	$742.99
Rate for Payer: Cash Price	$1,424.80
Rate for Payer: Cash Price	$1,424.80
Rate for Payer: Mclaren Medicaid	$285.21
Rate for Payer: Meridian Medicaid	$299.47
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,335.75
Rate for Payer: Priority Health Choice Medicaid	$285.21
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$798.99
Rate for Payer: Priority Health Narrow/Tiered Network	$798.99
Rate for Payer: UHC Medicaid	$285.21
Rate for Payer: UHCCP Medicaid	$285.21

PR TCD STD ICR ART VEN-ARTL SHNT DETCJ IV MBUBB NJX

Professional

Both

$695.00

Service Code	HCPCS 93893
Min. Negotiated Rate	$176.86
Max. Negotiated Rate	$521.25
Rate for Payer: Aetna Commercial	$176.86
Rate for Payer: Aetna Medicare	$347.50
Rate for Payer: BCN Commercial	$498.48
Rate for Payer: Cash Price	$556.00
Rate for Payer: Cash Price	$556.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$521.25
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$459.71
Rate for Payer: Priority Health Narrow/Tiered Network	$459.71

PR TDAP VACCINE 7 YRS/> IM

Professional

Both

$58.00

Service Code	HCPCS 90715
Min. Negotiated Rate	$29.00
Max. Negotiated Rate	$48.75
Rate for Payer: Aetna Commercial	$38.31
Rate for Payer: Aetna Medicare	$29.00
Rate for Payer: BCBS Trust/PPO	$48.75
Rate for Payer: BCN Commercial	$48.04
Rate for Payer: Cash Price	$46.40
Rate for Payer: Cash Price	$46.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$43.50

PR TDN TRNSPLJ/TR FLXR/XTNSR F/ARM&/WRST 1 EA TDN

Professional

Both

$2,712.00

Service Code	HCPCS 25310
Min. Negotiated Rate	$426.21
Max. Negotiated Rate	$2,034.00
Rate for Payer: Aetna Commercial	$826.01
Rate for Payer: Aetna Medicare	$1,356.00
Rate for Payer: BCBS Complete	$447.52
Rate for Payer: BCN Commercial	$1,093.07
Rate for Payer: Cash Price	$2,169.60
Rate for Payer: Cash Price	$2,169.60
Rate for Payer: Mclaren Medicaid	$426.21
Rate for Payer: Meridian Medicaid	$447.52
Rate for Payer: Opus (Opus Packaging Group) HMA	$2,034.00
Rate for Payer: Priority Health Choice Medicaid	$426.21
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$1,168.47
Rate for Payer: Priority Health Narrow/Tiered Network	$1,168.47
Rate for Payer: UHC Medicaid	$426.21
Rate for Payer: UHCCP Medicaid	$426.21

PR TDN TRNSPLJ/TR FLXR/XTNSR F/ARM&/WRST 1/TDN GR

Professional

Both

$1,630.00

Service Code	HCPCS 25312
Min. Negotiated Rate	$423.44
Max. Negotiated Rate	$1,222.50
Rate for Payer: Aetna Commercial	$951.85
Rate for Payer: Aetna Medicare	$815.00
Rate for Payer: BCBS Complete	$444.61
Rate for Payer: BCN Commercial	$1,099.54
Rate for Payer: Cash Price	$1,304.00
Rate for Payer: Cash Price	$1,304.00
Rate for Payer: Mclaren Medicaid	$423.44
Rate for Payer: Meridian Medicaid	$444.61
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,222.50
Rate for Payer: Priority Health Choice Medicaid	$423.44
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$1,175.38
Rate for Payer: Priority Health Narrow/Tiered Network	$1,175.38
Rate for Payer: UHC Medicaid	$423.44
Rate for Payer: UHCCP Medicaid	$423.44

PR TD VACCINE PRSRV FREE 7 YRS OR OLDER FOR IM USE

Professional

Both

$40.00

Service Code	HCPCS 90714
Min. Negotiated Rate	$20.00
Max. Negotiated Rate	$45.91
Rate for Payer: Aetna Commercial	$30.34
Rate for Payer: Aetna Medicare	$20.00
Rate for Payer: BCBS Trust/PPO	$45.91
Rate for Payer: BCN Commercial	$39.41
Rate for Payer: Cash Price	$32.00
Rate for Payer: Cash Price	$32.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$30.00

PR TEAEC W/GRAFT EA ADDL TIBIAL/PERONEAL ART

Professional

Both

$970.00

Service Code	HCPCS 35306
Min. Negotiated Rate	$256.67
Max. Negotiated Rate	$727.50
Rate for Payer: Aetna Commercial	$600.76
Rate for Payer: Aetna Medicare	$485.00
Rate for Payer: BCBS Complete	$269.50
Rate for Payer: BCN Commercial	$647.87
Rate for Payer: Cash Price	$776.00
Rate for Payer: Cash Price	$776.00
Rate for Payer: Mclaren Medicaid	$256.67
Rate for Payer: Meridian Medicaid	$269.50
Rate for Payer: Opus (Opus Packaging Group) HMA	$727.50
Rate for Payer: Priority Health Choice Medicaid	$256.67
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$696.71
Rate for Payer: Priority Health Narrow/Tiered Network	$696.71
Rate for Payer: UHC Medicaid	$256.67
Rate for Payer: UHCCP Medicaid	$256.67

Know your out-of-pocket cost for care.

All Charges