Bronson Lakeview Hospital

All Charges

Charge

Type

Setting

Price

REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM

Facility

$303.32

Service Code	CPT 12052
Hospital Revenue Code	360
Min. Negotiated Rate	$288.86
Max. Negotiated Rate	$303.32
Rate for Payer: BCBS Complete	$303.32
Rate for Payer: Mclaren Medicaid	$288.86
Rate for Payer: Meridian Medicaid	$303.32
Rate for Payer: Priority Health Choice Medicaid	$288.86
Rate for Payer: UHCCP Medicaid	$288.86

REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM

Facility

$303.32

Service Code	CPT 12053
Hospital Revenue Code	360
Min. Negotiated Rate	$288.86
Max. Negotiated Rate	$303.32
Rate for Payer: BCBS Complete	$303.32
Rate for Payer: Mclaren Medicaid	$288.86
Rate for Payer: Meridian Medicaid	$303.32
Rate for Payer: Priority Health Choice Medicaid	$288.86
Rate for Payer: UHCCP Medicaid	$288.86

REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.5 CM OR LESS

Facility

$303.32

Service Code	CPT 12041
Hospital Revenue Code	360
Min. Negotiated Rate	$288.86
Max. Negotiated Rate	$303.32
Rate for Payer: BCBS Complete	$303.32
Rate for Payer: Mclaren Medicaid	$288.86
Rate for Payer: Meridian Medicaid	$303.32
Rate for Payer: Priority Health Choice Medicaid	$288.86
Rate for Payer: UHCCP Medicaid	$288.86

REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM

Facility

$303.32

Service Code	CPT 12042
Hospital Revenue Code	360
Min. Negotiated Rate	$288.86
Max. Negotiated Rate	$303.32
Rate for Payer: BCBS Complete	$303.32
Rate for Payer: Mclaren Medicaid	$288.86
Rate for Payer: Meridian Medicaid	$303.32
Rate for Payer: Priority Health Choice Medicaid	$288.86
Rate for Payer: UHCCP Medicaid	$288.86

REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM

Facility

$303.32

Service Code	CPT 12035
Hospital Revenue Code	360
Min. Negotiated Rate	$288.86
Max. Negotiated Rate	$303.32
Rate for Payer: BCBS Complete	$303.32
Rate for Payer: Mclaren Medicaid	$288.86
Rate for Payer: Meridian Medicaid	$303.32
Rate for Payer: Priority Health Choice Medicaid	$288.86
Rate for Payer: UHCCP Medicaid	$288.86

REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.5 CM OR LESS

Facility

$303.32

Service Code	CPT 12031
Hospital Revenue Code	360
Min. Negotiated Rate	$288.86
Max. Negotiated Rate	$303.32
Rate for Payer: BCBS Complete	$303.32
Rate for Payer: Mclaren Medicaid	$288.86
Rate for Payer: Meridian Medicaid	$303.32
Rate for Payer: Priority Health Choice Medicaid	$288.86
Rate for Payer: UHCCP Medicaid	$288.86

REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM

Facility

$303.32

Service Code	CPT 12032
Hospital Revenue Code	360
Min. Negotiated Rate	$288.86
Max. Negotiated Rate	$303.32
Rate for Payer: BCBS Complete	$303.32
Rate for Payer: Mclaren Medicaid	$288.86
Rate for Payer: Meridian Medicaid	$303.32
Rate for Payer: Priority Health Choice Medicaid	$288.86
Rate for Payer: UHCCP Medicaid	$288.86

REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM

Facility

$303.32

Service Code	CPT 12034
Hospital Revenue Code	360
Min. Negotiated Rate	$288.86
Max. Negotiated Rate	$303.32
Rate for Payer: BCBS Complete	$303.32
Rate for Payer: Mclaren Medicaid	$288.86
Rate for Payer: Meridian Medicaid	$303.32
Rate for Payer: Priority Health Choice Medicaid	$288.86
Rate for Payer: UHCCP Medicaid	$288.86

REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); 3 CM TO 10 CM, INCARCERATED OR STRANGULATED

Facility

$4,429.45

Service Code	CPT 49594
Hospital Revenue Code	360
Min. Negotiated Rate	$4,218.24
Max. Negotiated Rate	$4,429.45
Rate for Payer: BCBS Complete	$4,429.45
Rate for Payer: Mclaren Medicaid	$4,218.24
Rate for Payer: Meridian Medicaid	$4,429.45
Rate for Payer: Priority Health Choice Medicaid	$4,218.24
Rate for Payer: UHCCP Medicaid	$4,218.24

Facility

$4,737.22

Service Code	CPT 49593
Hospital Revenue Code	360
Min. Negotiated Rate	$4,511.34
Max. Negotiated Rate	$4,737.22
Rate for Payer: BCBS Complete	$4,737.22
Rate for Payer: Mclaren Medicaid	$4,511.34
Rate for Payer: Meridian Medicaid	$4,737.22
Rate for Payer: Priority Health Choice Medicaid	$4,511.34
Rate for Payer: UHCCP Medicaid	$4,511.34

Facility

$4,429.45

Service Code	CPT 49592
Hospital Revenue Code	360
Min. Negotiated Rate	$4,218.24
Max. Negotiated Rate	$4,429.45
Rate for Payer: BCBS Complete	$4,429.45
Rate for Payer: Mclaren Medicaid	$4,218.24
Rate for Payer: Meridian Medicaid	$4,429.45
Rate for Payer: Priority Health Choice Medicaid	$4,218.24
Rate for Payer: UHCCP Medicaid	$4,218.24

Facility

$2,679.26

Service Code	CPT 49591
Hospital Revenue Code	360
Min. Negotiated Rate	$2,551.51
Max. Negotiated Rate	$2,679.26
Rate for Payer: BCBS Complete	$2,679.26
Rate for Payer: Mclaren Medicaid	$2,551.51
Rate for Payer: Meridian Medicaid	$2,679.26
Rate for Payer: Priority Health Choice Medicaid	$2,551.51
Rate for Payer: UHCCP Medicaid	$2,551.51

REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), RECURRENT, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); LESS THAN 3 CM, INCARCERATED OR STRANGULATED

Facility

$4,429.45

Service Code	CPT 49614
Hospital Revenue Code	360
Min. Negotiated Rate	$4,218.24
Max. Negotiated Rate	$4,429.45
Rate for Payer: BCBS Complete	$4,429.45
Rate for Payer: Mclaren Medicaid	$4,218.24
Rate for Payer: Meridian Medicaid	$4,429.45
Rate for Payer: Priority Health Choice Medicaid	$4,218.24
Rate for Payer: UHCCP Medicaid	$4,218.24

Facility

$2,679.26

Service Code	CPT 49613
Hospital Revenue Code	360
Min. Negotiated Rate	$2,551.51
Max. Negotiated Rate	$2,679.26
Rate for Payer: BCBS Complete	$2,679.26
Rate for Payer: Mclaren Medicaid	$2,551.51
Rate for Payer: Meridian Medicaid	$2,679.26
Rate for Payer: Priority Health Choice Medicaid	$2,551.51
Rate for Payer: UHCCP Medicaid	$2,551.51

REPAIR RECURRENT INGUINAL HERNIA, ANY AGE; INCARCERATED OR STRANGULATED

Facility

$4,737.22

Service Code	CPT 49521
Hospital Revenue Code	360
Min. Negotiated Rate	$4,511.34
Max. Negotiated Rate	$4,737.22
Rate for Payer: BCBS Complete	$4,737.22
Rate for Payer: Mclaren Medicaid	$4,511.34
Rate for Payer: Meridian Medicaid	$4,737.22
Rate for Payer: Priority Health Choice Medicaid	$4,511.34
Rate for Payer: UHCCP Medicaid	$4,511.34

REPAIR RECURRENT INGUINAL HERNIA, ANY AGE; REDUCIBLE

Facility

$2,679.26

Service Code	CPT 49520
Hospital Revenue Code	360
Min. Negotiated Rate	$2,551.51
Max. Negotiated Rate	$2,679.26
Rate for Payer: BCBS Complete	$2,679.26
Rate for Payer: Mclaren Medicaid	$2,551.51
Rate for Payer: Meridian Medicaid	$2,679.26
Rate for Payer: Priority Health Choice Medicaid	$2,551.51
Rate for Payer: UHCCP Medicaid	$2,551.51

REPAIR, TENDON, EXTENSOR, FOOT; PRIMARY OR SECONDARY, EACH TENDON

Facility

$2,463.31

Service Code	CPT 28208
Hospital Revenue Code	360
Min. Negotiated Rate	$2,345.85
Max. Negotiated Rate	$2,463.31
Rate for Payer: BCBS Complete	$2,463.31
Rate for Payer: Mclaren Medicaid	$2,345.85
Rate for Payer: Meridian Medicaid	$2,463.31
Rate for Payer: Priority Health Choice Medicaid	$2,345.85
Rate for Payer: UHCCP Medicaid	$2,345.85

REPLACEMENT OF GASTROSTOMY TUBE, PERCUTANEOUS, INCLUDES REMOVAL, WHEN PERFORMED, WITHOUT IMAGING OR ENDOSCOPIC GUIDANCE; NOT REQUIRING REVISION OF GASTROSTOMY TRACT

Facility

$184.65

Service Code	CPT 43762
Hospital Revenue Code	360
Min. Negotiated Rate	$175.84
Max. Negotiated Rate	$184.65
Rate for Payer: BCBS Complete	$184.65
Rate for Payer: Mclaren Medicaid	$175.84
Rate for Payer: Meridian Medicaid	$184.65
Rate for Payer: Priority Health Choice Medicaid	$175.84
Rate for Payer: UHCCP Medicaid	$175.84

RESECTION, PARTIAL OR COMPLETE, PHALANGEAL BASE, EACH TOE

Facility

$2,463.31

Service Code	CPT 28126
Hospital Revenue Code	360
Min. Negotiated Rate	$2,345.85
Max. Negotiated Rate	$2,463.31
Rate for Payer: BCBS Complete	$2,463.31
Rate for Payer: Mclaren Medicaid	$2,345.85
Rate for Payer: Meridian Medicaid	$2,463.31
Rate for Payer: Priority Health Choice Medicaid	$2,345.85
Rate for Payer: UHCCP Medicaid	$2,345.85

RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG) INTRAMUSCULAR SYRINGE

Facility

$287.31

Service Code	HCPCS J2790
Hospital Charge Code	11283
Hospital Revenue Code	636
Min. Negotiated Rate	$68.24
Max. Negotiated Rate	$258.58
Rate for Payer: Aetna Commercial	$244.21
Rate for Payer: Aetna Medicare	$74.70
Rate for Payer: Allen County Amish Medical Aid Commercial	$89.78
Rate for Payer: Amish Plain Church Group Commercial	$89.78
Rate for Payer: BCBS Complete	$114.92
Rate for Payer: BCBS MAPPO	$71.83
Rate for Payer: BCBS Trust/PPO	$236.20
Rate for Payer: BCN Commercial	$223.38
Rate for Payer: BCN Medicare Advantage	$71.83
Rate for Payer: Cash Price	$229.85
Rate for Payer: Cofinity Commercial	$247.09
Rate for Payer: Encore Health Key Benefits Commercial	$229.85
Rate for Payer: Health Alliance Plan Medicare Advantage	$71.83
Rate for Payer: Healthscope Commercial	$258.58
Rate for Payer: Lakeland Regional Health Systems Commercial	$215.48
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$75.42
Rate for Payer: MI Amish Medical Board Commercial	$82.60
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$244.21
Rate for Payer: Nomi Health Commercial	$235.59
Rate for Payer: PACE Senior Care Partners	$68.24
Rate for Payer: PACE SWMI	$71.83
Rate for Payer: PHP Commercial	$244.21
Rate for Payer: PHP Medicare Advantage	$71.83
Rate for Payer: Priority Health Cigna Priority Health	$186.75
Rate for Payer: Priority Health HMO/PPO	$249.96
Rate for Payer: Priority Health Medicare	$72.55
Rate for Payer: Priority Health Narrow/Tiered Network	$192.50
Rate for Payer: Railroad Medicare Medicare	$71.83
Rate for Payer: UHC All Payor (Choice/PPO)	$252.83
Rate for Payer: UHC Core	$239.90
Rate for Payer: UHC Dual Complete DSNP	$71.83
Rate for Payer: UHC Exchange	$71.83
Rate for Payer: UHC Medicare Advantage	$71.83
Rate for Payer: VA VA	$71.83
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$215.48

RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG) INTRAMUSCULAR SYRINGE

Facility

$287.31

Service Code	HCPCS J2790
Hospital Charge Code	11283
Hospital Revenue Code	636
Min. Negotiated Rate	$186.75
Max. Negotiated Rate	$258.58
Rate for Payer: Aetna Commercial	$244.21
Rate for Payer: BCBS Trust/PPO	$234.53
Rate for Payer: BCN Commercial	$222.03
Rate for Payer: Cash Price	$229.85
Rate for Payer: Cofinity Commercial	$247.09
Rate for Payer: Encore Health Key Benefits Commercial	$229.85
Rate for Payer: Healthscope Commercial	$258.58
Rate for Payer: Lakeland Regional Health Systems Commercial	$215.48
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$244.21
Rate for Payer: Nomi Health Commercial	$235.59
Rate for Payer: PHP Commercial	$244.21
Rate for Payer: Priority Health Cigna Priority Health	$186.75
Rate for Payer: Priority Health HMO/PPO	$249.96
Rate for Payer: Priority Health Narrow/Tiered Network	$192.50
Rate for Payer: UHC All Payor (Choice/PPO)	$252.83
Rate for Payer: UHC Core	$239.90
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$215.48

RIFAXIMIN 550 MG TABLET

Facility

$11,242.53

Service Code	NDC 65649030303
Hospital Charge Code	104604
Hospital Revenue Code	637
Min. Negotiated Rate	$2,670.10
Max. Negotiated Rate	$10,118.28
Rate for Payer: Aetna Commercial	$9,556.15
Rate for Payer: Aetna Medicare	$2,923.06
Rate for Payer: Allen County Amish Medical Aid Commercial	$3,513.29
Rate for Payer: Amish Plain Church Group Commercial	$3,513.29
Rate for Payer: BCBS Complete	$4,497.01
Rate for Payer: BCBS MAPPO	$2,810.63
Rate for Payer: BCBS Trust/PPO	$9,242.48
Rate for Payer: BCN Commercial	$8,741.07
Rate for Payer: BCN Medicare Advantage	$2,810.63
Rate for Payer: Cash Price	$8,994.02
Rate for Payer: Cofinity Commercial	$9,668.58
Rate for Payer: Encore Health Key Benefits Commercial	$8,994.02
Rate for Payer: Health Alliance Plan Medicare Advantage	$2,810.63
Rate for Payer: Healthscope Commercial	$10,118.28
Rate for Payer: Lakeland Regional Health Systems Commercial	$8,431.90
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$2,951.16
Rate for Payer: MI Amish Medical Board Commercial	$3,232.23
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$9,556.15
Rate for Payer: Nomi Health Commercial	$9,218.87
Rate for Payer: PACE Senior Care Partners	$2,670.10
Rate for Payer: PACE SWMI	$2,810.63
Rate for Payer: PHP Commercial	$9,556.15
Rate for Payer: PHP Medicare Advantage	$2,810.63
Rate for Payer: Priority Health Cigna Priority Health	$7,307.64
Rate for Payer: Priority Health HMO/PPO	$9,781.00
Rate for Payer: Priority Health Medicare	$2,838.74
Rate for Payer: Priority Health Narrow/Tiered Network	$7,532.50
Rate for Payer: Railroad Medicare Medicare	$2,810.63
Rate for Payer: UHC All Payor (Choice/PPO)	$9,893.43
Rate for Payer: UHC Core	$9,387.51
Rate for Payer: UHC Dual Complete DSNP	$2,810.63
Rate for Payer: UHC Exchange	$2,810.63
Rate for Payer: UHC Medicare Advantage	$2,810.63
Rate for Payer: VA VA	$2,810.63
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$8,431.90

RIFAXIMIN 550 MG TABLET

Facility

$11,242.53

Service Code	NDC 65649030303
Hospital Charge Code	104604
Hospital Revenue Code	637
Min. Negotiated Rate	$7,307.64
Max. Negotiated Rate	$10,118.28
Rate for Payer: Aetna Commercial	$9,556.15
Rate for Payer: BCBS Trust/PPO	$9,177.28
Rate for Payer: BCN Commercial	$8,688.23
Rate for Payer: Cash Price	$8,994.02
Rate for Payer: Cofinity Commercial	$9,668.58
Rate for Payer: Encore Health Key Benefits Commercial	$8,994.02
Rate for Payer: Healthscope Commercial	$10,118.28
Rate for Payer: Lakeland Regional Health Systems Commercial	$8,431.90
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$9,556.15
Rate for Payer: Nomi Health Commercial	$9,218.87
Rate for Payer: PHP Commercial	$9,556.15
Rate for Payer: Priority Health Cigna Priority Health	$7,307.64
Rate for Payer: Priority Health HMO/PPO	$9,781.00
Rate for Payer: Priority Health Narrow/Tiered Network	$7,532.50
Rate for Payer: UHC All Payor (Choice/PPO)	$9,893.43
Rate for Payer: UHC Core	$9,387.51
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$8,431.90

RISPERIDONE 0.25 MG TABLET

Facility

$38.07

Service Code	NDC 68382011214
Hospital Charge Code	25519
Hospital Revenue Code	637
Min. Negotiated Rate	$9.04
Max. Negotiated Rate	$34.26
Rate for Payer: Aetna Commercial	$32.36
Rate for Payer: Aetna Medicare	$9.90
Rate for Payer: Allen County Amish Medical Aid Commercial	$11.90
Rate for Payer: Amish Plain Church Group Commercial	$11.90
Rate for Payer: BCBS Complete	$15.23
Rate for Payer: BCBS MAPPO	$9.52
Rate for Payer: BCBS Trust/PPO	$31.30
Rate for Payer: BCN Commercial	$29.60
Rate for Payer: BCN Medicare Advantage	$9.52
Rate for Payer: Cash Price	$30.46
Rate for Payer: Cofinity Commercial	$32.74
Rate for Payer: Encore Health Key Benefits Commercial	$30.46
Rate for Payer: Health Alliance Plan Medicare Advantage	$9.52
Rate for Payer: Healthscope Commercial	$34.26
Rate for Payer: Lakeland Regional Health Systems Commercial	$28.55
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$9.99
Rate for Payer: MI Amish Medical Board Commercial	$10.95
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$32.36
Rate for Payer: Nomi Health Commercial	$31.22
Rate for Payer: PACE Senior Care Partners	$9.04
Rate for Payer: PACE SWMI	$9.52
Rate for Payer: PHP Commercial	$32.36
Rate for Payer: PHP Medicare Advantage	$9.52
Rate for Payer: Priority Health Cigna Priority Health	$24.75
Rate for Payer: Priority Health HMO/PPO	$33.12
Rate for Payer: Priority Health Medicare	$9.61
Rate for Payer: Priority Health Narrow/Tiered Network	$25.51
Rate for Payer: Railroad Medicare Medicare	$9.52
Rate for Payer: UHC All Payor (Choice/PPO)	$33.50
Rate for Payer: UHC Core	$31.79
Rate for Payer: UHC Dual Complete DSNP	$9.52
Rate for Payer: UHC Exchange	$9.52
Rate for Payer: UHC Medicare Advantage	$9.52
Rate for Payer: VA VA	$9.52
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$28.55

RISPERIDONE 0.25 MG TABLET

Facility

$38.07

Service Code	NDC 68382011214
Hospital Charge Code	25519
Hospital Revenue Code	637
Min. Negotiated Rate	$24.75
Max. Negotiated Rate	$34.26
Rate for Payer: Aetna Commercial	$32.36
Rate for Payer: BCBS Trust/PPO	$31.08
Rate for Payer: BCN Commercial	$29.42
Rate for Payer: Cash Price	$30.46
Rate for Payer: Cofinity Commercial	$32.74
Rate for Payer: Encore Health Key Benefits Commercial	$30.46
Rate for Payer: Healthscope Commercial	$34.26
Rate for Payer: Lakeland Regional Health Systems Commercial	$28.55
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$32.36
Rate for Payer: Nomi Health Commercial	$31.22
Rate for Payer: PHP Commercial	$32.36
Rate for Payer: Priority Health Cigna Priority Health	$24.75
Rate for Payer: Priority Health HMO/PPO	$33.12
Rate for Payer: Priority Health Narrow/Tiered Network	$25.51
Rate for Payer: UHC All Payor (Choice/PPO)	$33.50
Rate for Payer: UHC Core	$31.79
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$28.55

Know your out-of-pocket cost for care.

All Charges