Bronson Lakeview Hospital

All Charges

Charge

Type

Setting

Price

PR TYMPANOPLASTY W/O MASTOIDEC 1ST/REVJ PROSTH TORP

Professional

Both

$1,945.00

Service Code	HCPCS 69633
Min. Negotiated Rate	$601.51
Max. Negotiated Rate	$1,571.13
Rate for Payer: Aetna Commercial	$1,193.27
Rate for Payer: Aetna Medicare	$972.50
Rate for Payer: BCBS Complete	$631.59
Rate for Payer: BCN Commercial	$1,571.13
Rate for Payer: Cash Price	$1,556.00
Rate for Payer: Cash Price	$1,556.00
Rate for Payer: Mclaren Medicaid	$601.51
Rate for Payer: Meridian Medicaid	$631.59
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,458.75
Rate for Payer: Priority Health Choice Medicaid	$601.51
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$1,552.43
Rate for Payer: Priority Health Narrow/Tiered Network	$1,552.43
Rate for Payer: UHC Medicaid	$601.51
Rate for Payer: UHCCP Medicaid	$601.51

PR TYMPANOPLASTY W/O MASTOIDECT W/O OSSICLE RECNSTJ

Professional

Both

$3,239.00

Service Code	HCPCS 69631
Min. Negotiated Rate	$509.71
Max. Negotiated Rate	$2,429.25
Rate for Payer: Aetna Commercial	$1,012.12
Rate for Payer: Aetna Medicare	$1,619.50
Rate for Payer: BCBS Complete	$535.20
Rate for Payer: BCN Commercial	$1,325.62
Rate for Payer: Cash Price	$2,591.20
Rate for Payer: Cash Price	$2,591.20
Rate for Payer: Mclaren Medicaid	$509.71
Rate for Payer: Meridian Medicaid	$535.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$2,429.25
Rate for Payer: Priority Health Choice Medicaid	$509.71
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$1,309.84
Rate for Payer: Priority Health Narrow/Tiered Network	$1,309.84
Rate for Payer: UHC Medicaid	$509.71
Rate for Payer: UHCCP Medicaid	$509.71

PR TYMPANOSTOMY GENERAL ANESTHESIA

Professional

Both

$388.00

Service Code	HCPCS 69436
Min. Negotiated Rate	$92.23
Max. Negotiated Rate	$291.00
Rate for Payer: Aetna Commercial	$176.44
Rate for Payer: Aetna Medicare	$194.00
Rate for Payer: BCBS Complete	$96.84
Rate for Payer: BCN Commercial	$241.52
Rate for Payer: Cash Price	$310.40
Rate for Payer: Cash Price	$310.40
Rate for Payer: Mclaren Medicaid	$92.23
Rate for Payer: Meridian Medicaid	$96.84
Rate for Payer: Opus (Opus Packaging Group) HMA	$291.00
Rate for Payer: Priority Health Choice Medicaid	$92.23
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$238.65
Rate for Payer: Priority Health Narrow/Tiered Network	$238.65
Rate for Payer: UHC Medicaid	$92.23
Rate for Payer: UHCCP Medicaid	$92.23

PR TYMPANOSTOMY LOCAL/TOPICAL ANESTHESIA

Professional

Both

$339.00

Service Code	HCPCS 69433
Min. Negotiated Rate	$76.25
Max. Negotiated Rate	$254.25
Rate for Payer: Aetna Commercial	$145.46
Rate for Payer: Aetna Medicare	$169.50
Rate for Payer: BCBS Complete	$80.06
Rate for Payer: BCN Commercial	$158.26
Rate for Payer: Cash Price	$271.20
Rate for Payer: Cash Price	$271.20
Rate for Payer: Mclaren Medicaid	$76.25
Rate for Payer: Meridian Medicaid	$80.06
Rate for Payer: Opus (Opus Packaging Group) HMA	$254.25
Rate for Payer: Priority Health Choice Medicaid	$76.25
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$198.30
Rate for Payer: Priority Health Narrow/Tiered Network	$198.30
Rate for Payer: UHC Medicaid	$76.25
Rate for Payer: UHCCP Medicaid	$76.25

PR TYMPNOPLSTY W/O MSTDC 1ST/REVJ W/OSICLE RECNSTJ

Professional

Both

$2,013.00

Service Code	HCPCS 69632
Min. Negotiated Rate	$618.13
Max. Negotiated Rate	$1,612.96
Rate for Payer: Aetna Commercial	$1,230.77
Rate for Payer: Aetna Medicare	$1,006.50
Rate for Payer: BCBS Complete	$649.04
Rate for Payer: BCN Commercial	$1,612.96
Rate for Payer: Cash Price	$1,610.40
Rate for Payer: Cash Price	$1,610.40
Rate for Payer: Mclaren Medicaid	$618.13
Rate for Payer: Meridian Medicaid	$649.04
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,509.75
Rate for Payer: Priority Health Choice Medicaid	$618.13
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$1,593.76
Rate for Payer: Priority Health Narrow/Tiered Network	$1,593.76
Rate for Payer: UHC Medicaid	$618.13
Rate for Payer: UHCCP Medicaid	$618.13

PR TYMPP ANTRT/MASTOID W/O OSSICULAR CHAIN RECNSTJ

Professional

Both

$3,745.00

Service Code	HCPCS 69635
Min. Negotiated Rate	$749.97
Max. Negotiated Rate	$2,808.75
Rate for Payer: Aetna Commercial	$1,428.81
Rate for Payer: Aetna Medicare	$1,872.50
Rate for Payer: BCBS Complete	$787.47
Rate for Payer: BCN Commercial	$1,915.24
Rate for Payer: Cash Price	$2,996.00
Rate for Payer: Cash Price	$2,996.00
Rate for Payer: Mclaren Medicaid	$749.97
Rate for Payer: Meridian Medicaid	$787.47
Rate for Payer: Opus (Opus Packaging Group) HMA	$2,808.75
Rate for Payer: Priority Health Choice Medicaid	$749.97
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$1,892.45
Rate for Payer: Priority Health Narrow/Tiered Network	$1,892.45
Rate for Payer: UHC Medicaid	$749.97
Rate for Payer: UHCCP Medicaid	$749.97

PR UMBILECTOMY OMPHALECTOMY EXC UMBILICUS SPX

Professional

Both

$2,066.00

Service Code	HCPCS 49250
Min. Negotiated Rate	$362.31
Max. Negotiated Rate	$1,549.50
Rate for Payer: Aetna Commercial	$790.38
Rate for Payer: Aetna Medicare	$1,033.00
Rate for Payer: BCBS Complete	$380.43
Rate for Payer: BCN Commercial	$902.34
Rate for Payer: Cash Price	$1,652.80
Rate for Payer: Cash Price	$1,652.80
Rate for Payer: Mclaren Medicaid	$362.31
Rate for Payer: Meridian Medicaid	$380.43
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,549.50
Rate for Payer: Priority Health Choice Medicaid	$362.31
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$1,099.45
Rate for Payer: Priority Health Narrow/Tiered Network	$1,099.45
Rate for Payer: UHC Medicaid	$362.31
Rate for Payer: UHCCP Medicaid	$362.31

PR UNLISTED DIAGNOSTIC GASTROENTEROLOGY PROCEDURE

Professional

Both

$325.00

Service Code	HCPCS 91299
Min. Negotiated Rate	$162.50
Max. Negotiated Rate	$243.75
Rate for Payer: Aetna Medicare	$162.50
Rate for Payer: Cash Price	$260.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$243.75

PR UNLISTED EVALUATION AND MANAGEMENT SERVICE

Professional

Both

$47.00

Service Code	HCPCS 99499
Min. Negotiated Rate	$23.50
Max. Negotiated Rate	$35.25
Rate for Payer: Aetna Medicare	$23.50
Rate for Payer: Cash Price	$37.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$35.25

PR UNLISTED PSYCHIATRIC SERVICE/PROCEDURE

Professional

Both

$137.00

Service Code	HCPCS 90899
Min. Negotiated Rate	$68.50
Max. Negotiated Rate	$102.75
Rate for Payer: Aetna Medicare	$68.50
Rate for Payer: Cash Price	$109.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$102.75

PR UPG PACEMAKER SYS CONVERT 1CHMBR SYS 2CHMBR SYS

Professional

Both

$1,023.00

Service Code	HCPCS 33214
Min. Negotiated Rate	$271.36
Max. Negotiated Rate	$767.25
Rate for Payer: Aetna Commercial	$643.11
Rate for Payer: Aetna Medicare	$511.50
Rate for Payer: BCBS Complete	$284.93
Rate for Payer: BCN Commercial	$706.64
Rate for Payer: Cash Price	$818.40
Rate for Payer: Cash Price	$818.40
Rate for Payer: Mclaren Medicaid	$271.36
Rate for Payer: Meridian Medicaid	$284.93
Rate for Payer: Opus (Opus Packaging Group) HMA	$767.25
Rate for Payer: Priority Health Choice Medicaid	$271.36
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$759.90
Rate for Payer: Priority Health Narrow/Tiered Network	$759.90
Rate for Payer: UHC Medicaid	$271.36
Rate for Payer: UHCCP Medicaid	$271.36

PR UPPER EXT FX ORTHOSIS RAD/UL

Professional

Both

$361.00

Service Code	HCPCS L3982
Min. Negotiated Rate	$144.40
Max. Negotiated Rate	$420.64
Rate for Payer: Aetna Commercial	$215.32
Rate for Payer: Aetna Medicare	$180.50
Rate for Payer: BCBS Complete	$144.40
Rate for Payer: BCN Commercial	$420.64
Rate for Payer: Cash Price	$288.80
Rate for Payer: Cash Price	$288.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$270.75

PR UPPER EXT FX ORTHOSIS WRIST

Professional

Both

$317.00

Service Code	HCPCS L3984
Min. Negotiated Rate	$126.80
Max. Negotiated Rate	$370.55
Rate for Payer: Aetna Commercial	$189.68
Rate for Payer: Aetna Medicare	$158.50
Rate for Payer: BCBS Complete	$126.80
Rate for Payer: BCN Commercial	$370.55
Rate for Payer: Cash Price	$253.60
Rate for Payer: Cash Price	$253.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$237.75

PR UPPER GI ENDOSCOPY,STENT PLACEMENT

Professional

Both

$1,142.00

Service Code	HCPCS 43256
Min. Negotiated Rate	$456.80
Max. Negotiated Rate	$856.50
Rate for Payer: Aetna Medicare	$571.00
Rate for Payer: BCBS Complete	$456.80
Rate for Payer: Cash Price	$913.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$856.50

PR UPPER GI ENDOSCOPY,TUMOR ABLATN

Professional

Both

$1,257.00

Service Code	HCPCS 43258
Min. Negotiated Rate	$502.80
Max. Negotiated Rate	$942.75
Rate for Payer: Aetna Medicare	$628.50
Rate for Payer: BCBS Complete	$502.80
Rate for Payer: Cash Price	$1,005.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$942.75

PR UPPER LID BLEPHAROPLASTY

Professional

Both

$2,704.00

Hospital Revenue Code	990
Min. Negotiated Rate	$1,081.60
Max. Negotiated Rate	$2,028.00
Rate for Payer: Aetna Medicare	$1,352.00
Rate for Payer: BCBS Complete	$1,081.60
Rate for Payer: Cash Price	$2,163.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$2,028.00

PR URETERAL ENDOSCOPY VIA URETEROSTOMY

Professional

Both

$740.00

Service Code	HCPCS 50951
Min. Negotiated Rate	$171.68
Max. Negotiated Rate	$555.00
Rate for Payer: Aetna Commercial	$393.03
Rate for Payer: Aetna Medicare	$370.00
Rate for Payer: BCBS Complete	$180.26
Rate for Payer: BCN Commercial	$453.17
Rate for Payer: Cash Price	$592.00
Rate for Payer: Cash Price	$592.00
Rate for Payer: Mclaren Medicaid	$171.68
Rate for Payer: Meridian Medicaid	$180.26
Rate for Payer: Opus (Opus Packaging Group) HMA	$555.00
Rate for Payer: Priority Health Choice Medicaid	$171.68
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$493.64
Rate for Payer: Priority Health Narrow/Tiered Network	$493.64
Rate for Payer: UHC Medicaid	$171.68
Rate for Payer: UHCCP Medicaid	$171.68

PR URETERAL ENDOSCOPY VIA URETEROST W/RMVL FB/STONE

Professional

Both

$792.00

Service Code	HCPCS 50961
Min. Negotiated Rate	$178.07
Max. Negotiated Rate	$594.00
Rate for Payer: Aetna Commercial	$405.90
Rate for Payer: Aetna Medicare	$396.00
Rate for Payer: BCBS Complete	$186.97
Rate for Payer: BCN Commercial	$465.61
Rate for Payer: Cash Price	$633.60
Rate for Payer: Cash Price	$633.60
Rate for Payer: Mclaren Medicaid	$178.07
Rate for Payer: Meridian Medicaid	$186.97
Rate for Payer: Opus (Opus Packaging Group) HMA	$594.00
Rate for Payer: Priority Health Choice Medicaid	$178.07
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$507.20
Rate for Payer: Priority Health Narrow/Tiered Network	$507.20
Rate for Payer: UHC Medicaid	$178.07
Rate for Payer: UHCCP Medicaid	$178.07

PR URETEROILEAL CONDUIT W/INTESTINE ANASTOMOSIS

Professional

Both

$3,561.00

Service Code	HCPCS 50820
Min. Negotiated Rate	$751.68
Max. Negotiated Rate	$2,670.75
Rate for Payer: Aetna Commercial	$1,686.79
Rate for Payer: Aetna Medicare	$1,780.50
Rate for Payer: BCBS Complete	$789.26
Rate for Payer: BCN Commercial	$1,956.57
Rate for Payer: Cash Price	$2,848.80
Rate for Payer: Cash Price	$2,848.80
Rate for Payer: Mclaren Medicaid	$751.68
Rate for Payer: Meridian Medicaid	$789.26
Rate for Payer: Opus (Opus Packaging Group) HMA	$2,670.75
Rate for Payer: Priority Health Choice Medicaid	$751.68
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$2,131.33
Rate for Payer: Priority Health Narrow/Tiered Network	$2,131.33
Rate for Payer: UHC Medicaid	$751.68
Rate for Payer: UHCCP Medicaid	$751.68

PR URETEROLYSIS FOR OVARIAN VEIN SYNDROME

Professional

Both

$2,712.00

Service Code	HCPCS 50722
Min. Negotiated Rate	$576.38
Max. Negotiated Rate	$2,034.00
Rate for Payer: Aetna Commercial	$1,324.66
Rate for Payer: Aetna Medicare	$1,356.00
Rate for Payer: BCBS Complete	$605.20
Rate for Payer: BCN Commercial	$1,525.82
Rate for Payer: Cash Price	$2,169.60
Rate for Payer: Cash Price	$2,169.60
Rate for Payer: Mclaren Medicaid	$576.38
Rate for Payer: Meridian Medicaid	$605.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$2,034.00
Rate for Payer: Priority Health Choice Medicaid	$576.38
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$1,662.11
Rate for Payer: Priority Health Narrow/Tiered Network	$1,662.11
Rate for Payer: UHC Medicaid	$576.38
Rate for Payer: UHCCP Medicaid	$576.38

PR URETEROLYSIS W/WORPSG URETER RETROPERIT FIBROSIS

Professional

Both

$2,338.00

Service Code	HCPCS 50715
Min. Negotiated Rate	$713.98
Max. Negotiated Rate	$1,973.49
Rate for Payer: Aetna Commercial	$1,548.70
Rate for Payer: Aetna Medicare	$1,169.00
Rate for Payer: BCBS Complete	$749.68
Rate for Payer: BCN Commercial	$1,811.66
Rate for Payer: Cash Price	$1,870.40
Rate for Payer: Cash Price	$1,870.40
Rate for Payer: Mclaren Medicaid	$713.98
Rate for Payer: Meridian Medicaid	$749.68
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,753.50
Rate for Payer: Priority Health Choice Medicaid	$713.98
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$1,973.49
Rate for Payer: Priority Health Narrow/Tiered Network	$1,973.49
Rate for Payer: UHC Medicaid	$713.98
Rate for Payer: UHCCP Medicaid	$713.98

PR URETERONEOCYSTOSTOMY ANAST 1 URETER BLADDER

Professional

Both

$2,156.00

Service Code	HCPCS 50780
Min. Negotiated Rate	$641.98
Max. Negotiated Rate	$1,811.29
Rate for Payer: Aetna Commercial	$1,427.06
Rate for Payer: Aetna Medicare	$1,078.00
Rate for Payer: BCBS Complete	$674.08
Rate for Payer: BCN Commercial	$1,662.76
Rate for Payer: Cash Price	$1,724.80
Rate for Payer: Cash Price	$1,724.80
Rate for Payer: Mclaren Medicaid	$641.98
Rate for Payer: Meridian Medicaid	$674.08
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,617.00
Rate for Payer: Priority Health Choice Medicaid	$641.98
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$1,811.29
Rate for Payer: Priority Health Narrow/Tiered Network	$1,811.29
Rate for Payer: UHC Medicaid	$641.98
Rate for Payer: UHCCP Medicaid	$641.98

PR URETERONEOCYSTOSTOMY ANAST DUPLICATE URETER BLDR

Professional

Both

$2,303.00

Service Code	HCPCS 50782
Min. Negotiated Rate	$614.29
Max. Negotiated Rate	$1,745.65
Rate for Payer: Aetna Commercial	$1,378.95
Rate for Payer: Aetna Medicare	$1,151.50
Rate for Payer: BCBS Complete	$645.00
Rate for Payer: BCN Commercial	$1,602.51
Rate for Payer: Cash Price	$1,842.40
Rate for Payer: Cash Price	$1,842.40
Rate for Payer: Mclaren Medicaid	$614.29
Rate for Payer: Meridian Medicaid	$645.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,727.25
Rate for Payer: Priority Health Choice Medicaid	$614.29
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$1,745.65
Rate for Payer: Priority Health Narrow/Tiered Network	$1,745.65
Rate for Payer: UHC Medicaid	$614.29
Rate for Payer: UHCCP Medicaid	$614.29

PR URETERONEOCYSTOSTOMY W/URETERAL TAILORING

Professional

Both

$2,415.00

Service Code	HCPCS 50783
Min. Negotiated Rate	$642.83
Max. Negotiated Rate	$1,828.11
Rate for Payer: Aetna Commercial	$1,446.33
Rate for Payer: Aetna Medicare	$1,207.50
Rate for Payer: BCBS Complete	$674.97
Rate for Payer: BCN Commercial	$1,678.19
Rate for Payer: Cash Price	$1,932.00
Rate for Payer: Cash Price	$1,932.00
Rate for Payer: Mclaren Medicaid	$642.83
Rate for Payer: Meridian Medicaid	$674.97
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,811.25
Rate for Payer: Priority Health Choice Medicaid	$642.83
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$1,828.11
Rate for Payer: Priority Health Narrow/Tiered Network	$1,828.11
Rate for Payer: UHC Medicaid	$642.83
Rate for Payer: UHCCP Medicaid	$642.83

PR URETEROPYELOSTOMY ANAST URETER RENAL PELVIS

Professional

Both

$2,640.00

Service Code	HCPCS 50740
Min. Negotiated Rate	$735.70
Max. Negotiated Rate	$2,008.74
Rate for Payer: Aetna Commercial	$1,593.30
Rate for Payer: Aetna Medicare	$1,320.00
Rate for Payer: BCBS Complete	$772.49
Rate for Payer: BCN Commercial	$1,844.03
Rate for Payer: Cash Price	$2,112.00
Rate for Payer: Cash Price	$2,112.00
Rate for Payer: Mclaren Medicaid	$735.70
Rate for Payer: Meridian Medicaid	$772.49
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,980.00
Rate for Payer: Priority Health Choice Medicaid	$735.70
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$2,008.74
Rate for Payer: Priority Health Narrow/Tiered Network	$2,008.74
Rate for Payer: UHC Medicaid	$735.70
Rate for Payer: UHCCP Medicaid	$735.70

Know your out-of-pocket cost for care.

All Charges