Bronson Methodist Hospital

All Charges

Charge

Type

Setting

Price

PR RPR XTNSR TDN CNTRL SLIP TISS W/LAT BAND EA FNGR

Professional

Both

$1,944.00

Service Code	HCPCS 26426
Min. Negotiated Rate	$195.47
Max. Negotiated Rate	$1,360.80
Rate for Payer: Aetna Commercial	$669.62
Rate for Payer: BCBS Complete	$345.54
Rate for Payer: BCBS Trust/PPO	$195.47
Rate for Payer: Cash Price	$1,555.20
Rate for Payer: Cash Price	$1,555.20
Rate for Payer: Meridian Medicaid	$345.54
Rate for Payer: Priority Health Choice Medicaid	$329.09
Rate for Payer: Priority Health Cigna Priority Health	$1,360.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$780.79
Rate for Payer: Priority Health Narrow Network	$780.79
Rate for Payer: Priority Health SBD	$780.79
Rate for Payer: UMR Bronson Commercial	$894.24

PR RPSG PREV IMPLTED CAR VEN SYS L VENTR ELTRD

Professional

Both

$1,272.00

Service Code	HCPCS 33226
Min. Negotiated Rate	$305.66
Max. Negotiated Rate	$1,099.92
Rate for Payer: Aetna Commercial	$663.10
Rate for Payer: BCBS Complete	$320.94
Rate for Payer: BCBS Trust/PPO	$1,099.92
Rate for Payer: Cash Price	$1,017.60
Rate for Payer: Cash Price	$1,017.60
Rate for Payer: Meridian Medicaid	$320.94
Rate for Payer: Priority Health Choice Medicaid	$305.66
Rate for Payer: Priority Health Cigna Priority Health	$890.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$764.96
Rate for Payer: Priority Health Narrow Network	$764.96
Rate for Payer: Priority Health SBD	$764.96
Rate for Payer: UMR Bronson Commercial	$585.12

PR RPSG PREV IMPLTED PM/DFB R ATR/R VENTR ELECTRODE

Professional

Both

$1,009.00

Service Code	HCPCS 33215
Min. Negotiated Rate	$195.32
Max. Negotiated Rate	$1,453.88
Rate for Payer: Aetna Commercial	$415.09
Rate for Payer: BCBS Complete	$205.09
Rate for Payer: BCBS Trust/PPO	$1,453.88
Rate for Payer: Cash Price	$807.20
Rate for Payer: Cash Price	$807.20
Rate for Payer: Meridian Medicaid	$205.09
Rate for Payer: Priority Health Choice Medicaid	$195.32
Rate for Payer: Priority Health Cigna Priority Health	$706.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$488.33
Rate for Payer: Priority Health Narrow Network	$488.33
Rate for Payer: Priority Health SBD	$488.33
Rate for Payer: UMR Bronson Commercial	$464.14

PR RPSG PREVIOUSLY PLACED CVC UNDER FLUOR GDNCE

Professional

Both

$310.00

Service Code	HCPCS 36597
Min. Negotiated Rate	$37.49
Max. Negotiated Rate	$578.49
Rate for Payer: Aetna Commercial	$81.05
Rate for Payer: BCBS Complete	$39.36
Rate for Payer: BCBS Trust/PPO	$578.49
Rate for Payer: Cash Price	$248.00
Rate for Payer: Cash Price	$248.00
Rate for Payer: Meridian Medicaid	$39.36
Rate for Payer: Priority Health Choice Medicaid	$37.49
Rate for Payer: Priority Health Cigna Priority Health	$217.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$95.22
Rate for Payer: Priority Health Narrow Network	$95.22
Rate for Payer: Priority Health SBD	$95.22
Rate for Payer: UMR Bronson Commercial	$142.60

PR RSV MONOC ANTB SEASN 1 ML IM

Professional

Both

$1,277.00

Service Code	HCPCS 90381
Min. Negotiated Rate	$504.90
Max. Negotiated Rate	$893.90
Rate for Payer: Aetna Commercial	$504.90
Rate for Payer: BCBS Complete	$510.80
Rate for Payer: BCBS Trust/PPO	$504.90
Rate for Payer: Cash Price	$1,021.60
Rate for Payer: Cash Price	$1,021.60
Rate for Payer: Priority Health Cigna Priority Health	$893.90
Rate for Payer: UMR Bronson Commercial	$587.42

PR RSV MONOC ANTB SEASN .5ML IM

Professional

Both

$1,277.00

Service Code	HCPCS 90380
Min. Negotiated Rate	$504.90
Max. Negotiated Rate	$893.90
Rate for Payer: Aetna Commercial	$504.90
Rate for Payer: BCBS Complete	$510.80
Rate for Payer: BCBS Trust/PPO	$504.90
Rate for Payer: Cash Price	$1,021.60
Rate for Payer: Cash Price	$1,021.60
Rate for Payer: Priority Health Cigna Priority Health	$893.90
Rate for Payer: UMR Bronson Commercial	$587.42

PR RSV VACCINE PREF RECOMB SUBUNIT ADJUVANTED FOR IM USE

Professional

Both

$781.20

Service Code	HCPCS 90679
Min. Negotiated Rate	$285.60
Max. Negotiated Rate	$546.84
Rate for Payer: Aetna Commercial	$285.60
Rate for Payer: BCBS Complete	$312.48
Rate for Payer: BCBS Trust/PPO	$285.60
Rate for Payer: Cash Price	$624.96
Rate for Payer: Cash Price	$624.96
Rate for Payer: Priority Health Cigna Priority Health	$546.84
Rate for Payer: UMR Bronson Commercial	$359.35

PR RSV VACCINE PREF SUBUNIT BIVALENT FOR IM USE

Professional

Both

$823.05

Service Code	HCPCS 90678
Min. Negotiated Rate	$300.90
Max. Negotiated Rate	$576.14
Rate for Payer: Aetna Commercial	$300.90
Rate for Payer: BCBS Complete	$329.22
Rate for Payer: BCBS Trust/PPO	$347.00
Rate for Payer: Cash Price	$658.44
Rate for Payer: Cash Price	$658.44
Rate for Payer: Priority Health Cigna Priority Health	$576.14
Rate for Payer: UMR Bronson Commercial	$378.60

PR RTRVL INTRVAS VC FILTR W/WO ACS VSL SELXN RS&I

Professional

Both

$2,888.00

Service Code	HCPCS 37193
Min. Negotiated Rate	$214.92
Max. Negotiated Rate	$2,021.60
Rate for Payer: Aetna Commercial	$464.98
Rate for Payer: BCBS Complete	$225.67
Rate for Payer: BCBS Trust/PPO	$524.07
Rate for Payer: Cash Price	$2,310.40
Rate for Payer: Cash Price	$2,310.40
Rate for Payer: Meridian Medicaid	$225.67
Rate for Payer: Priority Health Choice Medicaid	$214.92
Rate for Payer: Priority Health Cigna Priority Health	$2,021.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$536.74
Rate for Payer: Priority Health Narrow Network	$536.74
Rate for Payer: Priority Health SBD	$536.74
Rate for Payer: UMR Bronson Commercial	$1,328.48

PR RUBELLA IMMUNIZATION, SUBCUT

Professional

Both

$30.00

Service Code	HCPCS 90706
Min. Negotiated Rate	$12.00
Max. Negotiated Rate	$21.00
Rate for Payer: BCBS Complete	$12.00
Rate for Payer: Cash Price	$24.00
Rate for Payer: Priority Health Cigna Priority Health	$21.00
Rate for Payer: UMR Bronson Commercial	$13.80

PR RV1 VACCINE 2 DOSE SCHEDULE LIVE FOR ORAL USE

Professional

Both

$156.00

Service Code	HCPCS 90681
Min. Negotiated Rate	$62.40
Max. Negotiated Rate	$137.29
Rate for Payer: Aetna Commercial	$137.29
Rate for Payer: BCBS Complete	$62.40
Rate for Payer: BCBS Trust/PPO	$129.14
Rate for Payer: Cash Price	$124.80
Rate for Payer: Cash Price	$124.80
Rate for Payer: Priority Health Cigna Priority Health	$109.20
Rate for Payer: UMR Bronson Commercial	$71.76

PR RV5 VACCINE 3 DOSE SCHEDULE LIVE FOR ORAL USE

Professional

Both

$94.00

Service Code	HCPCS 90680
Min. Negotiated Rate	$37.60
Max. Negotiated Rate	$97.75
Rate for Payer: Aetna Commercial	$97.75
Rate for Payer: BCBS Complete	$37.60
Rate for Payer: BCBS Trust/PPO	$91.96
Rate for Payer: Cash Price	$75.20
Rate for Payer: Cash Price	$75.20
Rate for Payer: Priority Health Cigna Priority Health	$65.80
Rate for Payer: UMR Bronson Commercial	$43.24

PR R VENTRIC RESCJ INFUND STEN W/WO COMMISSUROTOMY

Professional

Both

$3,080.00

Service Code	HCPCS 33476
Min. Negotiated Rate	$684.68
Max. Negotiated Rate	$2,385.29
Rate for Payer: Aetna Commercial	$2,042.75
Rate for Payer: BCBS Complete	$1,008.44
Rate for Payer: BCBS Trust/PPO	$684.68
Rate for Payer: Cash Price	$2,464.00
Rate for Payer: Cash Price	$2,464.00
Rate for Payer: Meridian Medicaid	$1,008.44
Rate for Payer: Priority Health Choice Medicaid	$960.42
Rate for Payer: Priority Health Cigna Priority Health	$2,156.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,385.29
Rate for Payer: Priority Health Narrow Network	$2,385.29
Rate for Payer: Priority Health SBD	$2,385.29
Rate for Payer: UMR Bronson Commercial	$1,416.80

PR RX&FITG C-LENS SUPVJ CRNL LENS OU XCPT APHK

Professional

Both

$162.00

Service Code	HCPCS 92310
Min. Negotiated Rate	$36.00
Max. Negotiated Rate	$310.64
Rate for Payer: Aetna Commercial	$64.40
Rate for Payer: BCBS Complete	$37.80
Rate for Payer: BCBS Trust/PPO	$310.64
Rate for Payer: Cash Price	$129.60
Rate for Payer: Cash Price	$129.60
Rate for Payer: Meridian Medicaid	$37.80
Rate for Payer: Priority Health Choice Medicaid	$36.00
Rate for Payer: Priority Health Cigna Priority Health	$113.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$67.85
Rate for Payer: Priority Health Narrow Network	$67.85
Rate for Payer: Priority Health SBD	$67.85
Rate for Payer: UMR Bronson Commercial	$74.52

PR RX&FTG CONTACT CORNEAL LENS EYES XCPT APHAKIA

Professional

Both

$134.00

Service Code	HCPCS 92314
Min. Negotiated Rate	$37.80
Max. Negotiated Rate	$686.79
Rate for Payer: Aetna Commercial	$37.80
Rate for Payer: BCBS Complete	$53.60
Rate for Payer: BCBS Trust/PPO	$686.79
Rate for Payer: Cash Price	$107.20
Rate for Payer: Cash Price	$107.20
Rate for Payer: Priority Health Cigna Priority Health	$93.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$40.15
Rate for Payer: Priority Health Narrow Network	$40.15
Rate for Payer: Priority Health SBD	$40.15
Rate for Payer: UMR Bronson Commercial	$61.64

PR RX RIB FRACTURE W EXTERN FIXATN

Professional

Both

$1,291.00

Service Code	HCPCS 21810
Min. Negotiated Rate	$516.40
Max. Negotiated Rate	$903.70
Rate for Payer: BCBS Complete	$516.40
Rate for Payer: Cash Price	$1,032.80
Rate for Payer: Priority Health Cigna Priority Health	$903.70
Rate for Payer: UMR Bronson Commercial	$593.86

PR SACRAL NERVE STIM TEST LEAD

Professional

Both

$160.00

Service Code	HCPCS A4290
Min. Negotiated Rate	$57.67
Max. Negotiated Rate	$902.34
Rate for Payer: Aetna Commercial	$57.67
Rate for Payer: BCBS Complete	$64.00
Rate for Payer: BCBS Trust/PPO	$902.34
Rate for Payer: Cash Price	$128.00
Rate for Payer: Cash Price	$128.00
Rate for Payer: Priority Health Cigna Priority Health	$112.00
Rate for Payer: UMR Bronson Commercial	$73.60

PR SALPINGECTOMY COMPLETE/PARTIAL UNI/BI SPX

Professional

Both

$1,715.00

Service Code	HCPCS 58700
Min. Negotiated Rate	$138.94
Max. Negotiated Rate	$1,200.50
Rate for Payer: Aetna Commercial	$948.70
Rate for Payer: BCBS Complete	$540.78
Rate for Payer: BCBS Trust/PPO	$138.94
Rate for Payer: Cash Price	$1,372.00
Rate for Payer: Cash Price	$1,372.00
Rate for Payer: Meridian Medicaid	$540.78
Rate for Payer: Priority Health Choice Medicaid	$515.03
Rate for Payer: Priority Health Cigna Priority Health	$1,200.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,137.64
Rate for Payer: Priority Health Narrow Network	$1,137.64
Rate for Payer: Priority Health SBD	$1,137.64
Rate for Payer: UMR Bronson Commercial	$788.90

PR SALPINGO-OOPHORECTOMY COMPL/PRTL UNI/BI SPX

Professional

Both

$2,001.00

Service Code	HCPCS 58720
Min. Negotiated Rate	$429.51
Max. Negotiated Rate	$1,400.70
Rate for Payer: Aetna Commercial	$897.45
Rate for Payer: BCBS Complete	$513.50
Rate for Payer: BCBS Trust/PPO	$429.51
Rate for Payer: Cash Price	$1,600.80
Rate for Payer: Cash Price	$1,600.80
Rate for Payer: Meridian Medicaid	$513.50
Rate for Payer: Priority Health Choice Medicaid	$489.05
Rate for Payer: Priority Health Cigna Priority Health	$1,400.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,077.03
Rate for Payer: Priority Health Narrow Network	$1,077.03
Rate for Payer: Priority Health SBD	$1,077.03
Rate for Payer: UMR Bronson Commercial	$920.46

PR SALPINGOSTOMY

Professional

Both

$2,674.00

Service Code	HCPCS 58770
Min. Negotiated Rate	$209.21
Max. Negotiated Rate	$1,871.80
Rate for Payer: Aetna Commercial	$1,032.82
Rate for Payer: BCBS Complete	$581.04
Rate for Payer: BCBS Trust/PPO	$209.21
Rate for Payer: Cash Price	$2,139.20
Rate for Payer: Cash Price	$2,139.20
Rate for Payer: Meridian Medicaid	$581.04
Rate for Payer: Priority Health Choice Medicaid	$553.37
Rate for Payer: Priority Health Cigna Priority Health	$1,871.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,226.65
Rate for Payer: Priority Health Narrow Network	$1,226.65
Rate for Payer: Priority Health SBD	$1,226.65
Rate for Payer: UMR Bronson Commercial	$1,230.04

PR SARSCOV2 VACC 10MCG/0.3ML TRIS-SUCROSE IM USE

Professional

Both

$214.83

Service Code	HCPCS 91319
Min. Negotiated Rate	$78.54
Max. Negotiated Rate	$150.38
Rate for Payer: Aetna Commercial	$87.78
Rate for Payer: BCBS Complete	$85.93
Rate for Payer: BCBS Trust/PPO	$78.54
Rate for Payer: Cash Price	$171.86
Rate for Payer: Cash Price	$171.86
Rate for Payer: Priority Health Cigna Priority Health	$150.38
Rate for Payer: UMR Bronson Commercial	$98.82

PR SARSCOV2 VACC 30MCG/0.3ML TRIS-SUCROSE IM USE

Professional

Both

$320.85

Service Code	HCPCS 91320
Min. Negotiated Rate	$125.00
Max. Negotiated Rate	$224.60
Rate for Payer: Aetna Commercial	$131.10
Rate for Payer: BCBS Complete	$128.34
Rate for Payer: BCBS Trust/PPO	$125.00
Rate for Payer: Cash Price	$256.68
Rate for Payer: Cash Price	$256.68
Rate for Payer: Priority Health Cigna Priority Health	$224.60
Rate for Payer: UMR Bronson Commercial	$147.59

PR SARSCOV2 VACC 3MCG/0.3ML TRIS-SUCROSE IM USE

Professional

Both

$160.44

Service Code	HCPCS 91318
Min. Negotiated Rate	$58.65
Max. Negotiated Rate	$112.31
Rate for Payer: Aetna Commercial	$65.36
Rate for Payer: BCBS Complete	$64.18
Rate for Payer: BCBS Trust/PPO	$58.65
Rate for Payer: Cash Price	$128.35
Rate for Payer: Cash Price	$128.35
Rate for Payer: Priority Health Cigna Priority Health	$112.31
Rate for Payer: UMR Bronson Commercial	$73.80

PR SBSQ HOSPITAL IP/OBS CARE HIGH MDM 50 MINUTES

Professional

Both

$180.00

Service Code	HCPCS 99233
Min. Negotiated Rate	$74.98
Max. Negotiated Rate	$1,858.56
Rate for Payer: Aetna Commercial	$101.64
Rate for Payer: BCBS Complete	$78.73
Rate for Payer: BCBS Trust/PPO	$1,858.56
Rate for Payer: Cash Price	$144.00
Rate for Payer: Cash Price	$144.00
Rate for Payer: Meridian Medicaid	$78.73
Rate for Payer: Priority Health Choice Medicaid	$74.98
Rate for Payer: Priority Health Cigna Priority Health	$126.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$150.77
Rate for Payer: Priority Health Narrow Network	$150.77
Rate for Payer: Priority Health SBD	$150.77
Rate for Payer: UMR Bronson Commercial	$82.80

PR SBSQ HOSPITAL IP/OBS CARE MOD MDM 35 MINUTES

Professional

Both

$126.00

Service Code	HCPCS 99232
Min. Negotiated Rate	$49.84
Max. Negotiated Rate	$2,072.52
Rate for Payer: Aetna Commercial	$70.74
Rate for Payer: BCBS Complete	$52.33
Rate for Payer: BCBS Trust/PPO	$2,072.52
Rate for Payer: Cash Price	$100.80
Rate for Payer: Cash Price	$100.80
Rate for Payer: Meridian Medicaid	$52.33
Rate for Payer: Priority Health Choice Medicaid	$49.84
Rate for Payer: Priority Health Cigna Priority Health	$88.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$100.23
Rate for Payer: Priority Health Narrow Network	$100.23
Rate for Payer: Priority Health SBD	$100.23
Rate for Payer: UMR Bronson Commercial	$57.96

Know your out-of-pocket cost for care.

All Charges