Bronson Methodist Hospital

All Charges

Charge

Type

Setting

Price

PR SIMPLE REPAIR F/E/E/N/L/M 2.6CM-5.0 CM

Professional

Both

$351.00

Service Code	HCPCS 12013
Min. Negotiated Rate	$36.85
Max. Negotiated Rate	$351.25
Rate for Payer: Aetna Commercial	$64.56
Rate for Payer: BCBS Complete	$38.69
Rate for Payer: BCBS Trust/PPO	$351.25
Rate for Payer: Cash Price	$280.80
Rate for Payer: Cash Price	$280.80
Rate for Payer: Meridian Medicaid	$38.69
Rate for Payer: Priority Health Choice Medicaid	$36.85
Rate for Payer: Priority Health Cigna Priority Health	$245.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$71.52
Rate for Payer: Priority Health Narrow Network	$71.52
Rate for Payer: Priority Health SBD	$71.52
Rate for Payer: UMR Bronson Commercial	$161.46

PR SIMPLE REPAIR F/E/E/N/L/M >30.0 CM

Professional

Both

$1,333.00

Service Code	HCPCS 12018
Min. Negotiated Rate	$28.95
Max. Negotiated Rate	$933.10
Rate for Payer: Aetna Commercial	$192.24
Rate for Payer: BCBS Complete	$115.85
Rate for Payer: BCBS Trust/PPO	$28.95
Rate for Payer: Cash Price	$1,066.40
Rate for Payer: Cash Price	$1,066.40
Rate for Payer: Meridian Medicaid	$115.85
Rate for Payer: Priority Health Choice Medicaid	$110.33
Rate for Payer: Priority Health Cigna Priority Health	$933.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$212.10
Rate for Payer: Priority Health Narrow Network	$212.10
Rate for Payer: Priority Health SBD	$212.10
Rate for Payer: UMR Bronson Commercial	$613.18

PR SIMPLE REPAIR F/E/E/N/L/M 5.1CM-7.5 CM

Professional

Both

$481.00

Service Code	HCPCS 12014
Min. Negotiated Rate	$47.71
Max. Negotiated Rate	$336.70
Rate for Payer: Aetna Commercial	$83.07
Rate for Payer: BCBS Complete	$50.10
Rate for Payer: BCBS Trust/PPO	$117.56
Rate for Payer: Cash Price	$384.80
Rate for Payer: Cash Price	$384.80
Rate for Payer: Meridian Medicaid	$50.10
Rate for Payer: Priority Health Choice Medicaid	$47.71
Rate for Payer: Priority Health Cigna Priority Health	$336.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$91.25
Rate for Payer: Priority Health Narrow Network	$91.25
Rate for Payer: Priority Health SBD	$91.25
Rate for Payer: UMR Bronson Commercial	$221.26

PR SIMPLE REPAIR F/E/E/N/L/M 7.6CM-12.5 CM

Professional

Both

$622.00

Service Code	HCPCS 12015
Min. Negotiated Rate	$59.85
Max. Negotiated Rate	$435.40
Rate for Payer: Aetna Commercial	$104.96
Rate for Payer: BCBS Complete	$62.84
Rate for Payer: BCBS Trust/PPO	$117.56
Rate for Payer: Cash Price	$497.60
Rate for Payer: Cash Price	$497.60
Rate for Payer: Meridian Medicaid	$62.84
Rate for Payer: Priority Health Choice Medicaid	$59.85
Rate for Payer: Priority Health Cigna Priority Health	$435.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$115.09
Rate for Payer: Priority Health Narrow Network	$115.09
Rate for Payer: Priority Health SBD	$115.09
Rate for Payer: UMR Bronson Commercial	$286.12

PR SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/<

Professional

Both

$249.00

Service Code	HCPCS 12001
Min. Negotiated Rate	$28.54
Max. Negotiated Rate	$556.23
Rate for Payer: Aetna Commercial	$48.72
Rate for Payer: BCBS Complete	$29.97
Rate for Payer: BCBS Trust/PPO	$556.23
Rate for Payer: Cash Price	$199.20
Rate for Payer: Cash Price	$199.20
Rate for Payer: Meridian Medicaid	$29.97
Rate for Payer: Priority Health Choice Medicaid	$28.54
Rate for Payer: Priority Health Cigna Priority Health	$174.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$55.08
Rate for Payer: Priority Health Narrow Network	$55.08
Rate for Payer: Priority Health SBD	$55.08
Rate for Payer: UMR Bronson Commercial	$114.54

PR SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK >30.0CM

Professional

Both

$540.00

Service Code	HCPCS 12007
Min. Negotiated Rate	$91.59
Max. Negotiated Rate	$378.00
Rate for Payer: Aetna Commercial	$161.43
Rate for Payer: BCBS Complete	$96.17
Rate for Payer: BCBS Trust/PPO	$305.57
Rate for Payer: Cash Price	$432.00
Rate for Payer: Cash Price	$432.00
Rate for Payer: Meridian Medicaid	$96.17
Rate for Payer: Priority Health Choice Medicaid	$91.59
Rate for Payer: Priority Health Cigna Priority Health	$378.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$176.74
Rate for Payer: Priority Health Narrow Network	$176.74
Rate for Payer: Priority Health SBD	$176.74
Rate for Payer: UMR Bronson Commercial	$248.40

PR SIMPLE RPR SCALP/NECK/AX/GENIT/TRUNK 7.6-12.5CM

Professional

Both

$372.00

Service Code	HCPCS 12004
Min. Negotiated Rate	$28.95
Max. Negotiated Rate	$260.40
Rate for Payer: Aetna Commercial	$80.43
Rate for Payer: BCBS Complete	$49.20
Rate for Payer: BCBS Trust/PPO	$28.95
Rate for Payer: Cash Price	$297.60
Rate for Payer: Cash Price	$297.60
Rate for Payer: Meridian Medicaid	$49.20
Rate for Payer: Priority Health Choice Medicaid	$46.86
Rate for Payer: Priority Health Cigna Priority Health	$260.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$89.20
Rate for Payer: Priority Health Narrow Network	$89.20
Rate for Payer: Priority Health SBD	$89.20
Rate for Payer: UMR Bronson Commercial	$171.12

PR SIMPLE UROFLOMETRY

Professional

Both

$88.00

Service Code	HCPCS 51736
Min. Negotiated Rate	$8.64
Max. Negotiated Rate	$3,043.01
Rate for Payer: Aetna Commercial	$16.86
Rate for Payer: BCBS Complete	$35.20
Rate for Payer: BCBS Trust/PPO	$3,043.01
Rate for Payer: Cash Price	$70.40
Rate for Payer: Cash Price	$70.40
Rate for Payer: Priority Health Cigna Priority Health	$61.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$8.64
Rate for Payer: Priority Health Narrow Network	$8.64
Rate for Payer: Priority Health SBD	$21.61
Rate for Payer: UMR Bronson Commercial	$40.48

PR SINUSOT FRNT NONOBLIT W/OSTPL FLAP CORONAL INC

Professional

Both

$2,101.00

Service Code	HCPCS 31087
Min. Negotiated Rate	$720.37
Max. Negotiated Rate	$1,569.26
Rate for Payer: Aetna Commercial	$1,421.59
Rate for Payer: BCBS Complete	$756.39
Rate for Payer: BCBS Trust/PPO	$896.53
Rate for Payer: Cash Price	$1,680.80
Rate for Payer: Cash Price	$1,680.80
Rate for Payer: Meridian Medicaid	$756.39
Rate for Payer: Priority Health Choice Medicaid	$720.37
Rate for Payer: Priority Health Cigna Priority Health	$1,470.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,569.26
Rate for Payer: Priority Health Narrow Network	$1,569.26
Rate for Payer: Priority Health SBD	$1,569.26
Rate for Payer: UMR Bronson Commercial	$966.46

PR SINUSOT FRNT OBLIT W/O OSTPL FLAP CORONAL INC

Professional

Both

$2,044.00

Service Code	HCPCS 31081
Min. Negotiated Rate	$750.83
Max. Negotiated Rate	$1,637.33
Rate for Payer: Aetna Commercial	$1,479.82
Rate for Payer: BCBS Complete	$788.37
Rate for Payer: BCBS Trust/PPO	$1,196.07
Rate for Payer: Cash Price	$1,635.20
Rate for Payer: Cash Price	$1,635.20
Rate for Payer: Meridian Medicaid	$788.37
Rate for Payer: Priority Health Choice Medicaid	$750.83
Rate for Payer: Priority Health Cigna Priority Health	$1,430.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,637.33
Rate for Payer: Priority Health Narrow Network	$1,637.33
Rate for Payer: Priority Health SBD	$1,637.33
Rate for Payer: UMR Bronson Commercial	$940.24

PR SINUSOT FRNT OBLIT W/OSTPL FLAP CORONAL INC

Professional

Both

$2,615.00

Service Code	HCPCS 31085
Min. Negotiated Rate	$792.45
Max. Negotiated Rate	$1,830.50
Rate for Payer: Aetna Commercial	$1,581.37
Rate for Payer: BCBS Complete	$840.47
Rate for Payer: BCBS Trust/PPO	$792.45
Rate for Payer: Cash Price	$2,092.00
Rate for Payer: Cash Price	$2,092.00
Rate for Payer: Meridian Medicaid	$840.47
Rate for Payer: Priority Health Choice Medicaid	$800.45
Rate for Payer: Priority Health Cigna Priority Health	$1,830.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,746.61
Rate for Payer: Priority Health Narrow Network	$1,746.61
Rate for Payer: Priority Health SBD	$1,746.61
Rate for Payer: UMR Bronson Commercial	$1,202.90

PR SINUSOT MAX ANTRT RAD W/RMVL ANTROCH POLYPS

Professional

Both

$1,102.00

Service Code	HCPCS 31032
Min. Negotiated Rate	$382.55
Max. Negotiated Rate	$854.26
Rate for Payer: Aetna Commercial	$753.09
Rate for Payer: BCBS Complete	$401.68
Rate for Payer: BCBS Trust/PPO	$854.26
Rate for Payer: Cash Price	$881.60
Rate for Payer: Cash Price	$881.60
Rate for Payer: Meridian Medicaid	$401.68
Rate for Payer: Priority Health Choice Medicaid	$382.55
Rate for Payer: Priority Health Cigna Priority Health	$771.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$834.41
Rate for Payer: Priority Health Narrow Network	$834.41
Rate for Payer: Priority Health SBD	$834.41
Rate for Payer: UMR Bronson Commercial	$506.92

PR SINUSOTOMY FRNT OBLITERATIVE W/O FLAP BROW INC

Professional

Both

$2,220.00

Service Code	HCPCS 31080
Min. Negotiated Rate	$700.77
Max. Negotiated Rate	$1,554.00
Rate for Payer: Aetna Commercial	$1,380.05
Rate for Payer: BCBS Complete	$735.81
Rate for Payer: BCBS Trust/PPO	$1,014.34
Rate for Payer: Cash Price	$1,776.00
Rate for Payer: Cash Price	$1,776.00
Rate for Payer: Meridian Medicaid	$735.81
Rate for Payer: Priority Health Choice Medicaid	$700.77
Rate for Payer: Priority Health Cigna Priority Health	$1,554.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,528.98
Rate for Payer: Priority Health Narrow Network	$1,528.98
Rate for Payer: Priority Health SBD	$1,528.98
Rate for Payer: UMR Bronson Commercial	$1,021.20

PR SINUSOTOMY FRONTAL EXTERNAL SIMPLE

Professional

Both

$869.00

Service Code	HCPCS 31070
Min. Negotiated Rate	$306.72
Max. Negotiated Rate	$1,016.45
Rate for Payer: Aetna Commercial	$597.38
Rate for Payer: BCBS Complete	$322.06
Rate for Payer: BCBS Trust/PPO	$1,016.45
Rate for Payer: Cash Price	$695.20
Rate for Payer: Cash Price	$695.20
Rate for Payer: Meridian Medicaid	$322.06
Rate for Payer: Priority Health Choice Medicaid	$306.72
Rate for Payer: Priority Health Cigna Priority Health	$608.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$670.49
Rate for Payer: Priority Health Narrow Network	$670.49
Rate for Payer: Priority Health SBD	$670.49
Rate for Payer: UMR Bronson Commercial	$399.74

PR SINUSOTOMY MAXILLARY ANTROTOMY INTRANASAL

Professional

Both

$700.00

Service Code	HCPCS 31020
Min. Negotiated Rate	$113.58
Max. Negotiated Rate	$495.92
Rate for Payer: Aetna Commercial	$488.09
Rate for Payer: BCBS Complete	$230.58
Rate for Payer: BCBS Trust/PPO	$113.58
Rate for Payer: Cash Price	$560.00
Rate for Payer: Cash Price	$560.00
Rate for Payer: Meridian Medicaid	$230.58
Rate for Payer: Priority Health Choice Medicaid	$219.60
Rate for Payer: Priority Health Cigna Priority Health	$490.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$495.92
Rate for Payer: Priority Health Narrow Network	$495.92
Rate for Payer: Priority Health SBD	$495.92
Rate for Payer: UMR Bronson Commercial	$322.00

PR SINUSOTOMY MAXILLARY RAD W/O RMVL ANTROCH POLYPS

Professional

Both

$1,133.00

Service Code	HCPCS 31030
Min. Negotiated Rate	$330.15
Max. Negotiated Rate	$793.10
Rate for Payer: Aetna Commercial	$651.88
Rate for Payer: BCBS Complete	$346.66
Rate for Payer: BCBS Trust/PPO	$665.66
Rate for Payer: Cash Price	$906.40
Rate for Payer: Cash Price	$906.40
Rate for Payer: Meridian Medicaid	$346.66
Rate for Payer: Priority Health Choice Medicaid	$330.15
Rate for Payer: Priority Health Cigna Priority Health	$793.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$712.62
Rate for Payer: Priority Health Narrow Network	$712.62
Rate for Payer: Priority Health SBD	$712.62
Rate for Payer: UMR Bronson Commercial	$521.18

PR SINUSOT SPHENOID W/MUCOSAL STRIPPING/RMVL POLYP

Professional

Both

$1,830.00

Service Code	HCPCS 31051
Min. Negotiated Rate	$446.87
Max. Negotiated Rate	$1,281.00
Rate for Payer: Aetna Commercial	$876.60
Rate for Payer: BCBS Complete	$469.21
Rate for Payer: BCBS Trust/PPO	$695.24
Rate for Payer: Cash Price	$1,464.00
Rate for Payer: Cash Price	$1,464.00
Rate for Payer: Meridian Medicaid	$469.21
Rate for Payer: Priority Health Choice Medicaid	$446.87
Rate for Payer: Priority Health Cigna Priority Health	$1,281.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$975.63
Rate for Payer: Priority Health Narrow Network	$975.63
Rate for Payer: Priority Health SBD	$975.63
Rate for Payer: UMR Bronson Commercial	$841.80

PR SKIN LESION SHAVE/EXCISION (15 MIN)

Professional

Both

$250.00

Service Code	HCPCS 00367
Hospital Revenue Code	990
Min. Negotiated Rate	$100.00
Max. Negotiated Rate	$175.00
Rate for Payer: BCBS Complete	$100.00
Rate for Payer: Cash Price	$200.00
Rate for Payer: Priority Health Cigna Priority Health	$175.00
Rate for Payer: UMR Bronson Commercial	$115.00

PR SKIN LESION SHAVE/EXCISION (30 MIN)

Professional

Both

$500.00

Service Code	HCPCS 00368
Hospital Revenue Code	990
Min. Negotiated Rate	$200.00
Max. Negotiated Rate	$350.00
Rate for Payer: BCBS Complete	$200.00
Rate for Payer: Cash Price	$400.00
Rate for Payer: Priority Health Cigna Priority Health	$350.00
Rate for Payer: UMR Bronson Commercial	$230.00

PR SKYLA, 13.5 MG

Professional

Both

$1,433.00

Service Code	HCPCS J7301
Min. Negotiated Rate	$659.18
Max. Negotiated Rate	$1,003.10
Rate for Payer: Aetna Commercial	$917.35
Rate for Payer: BCBS Complete	$963.22
Rate for Payer: BCBS Trust/PPO	$925.78
Rate for Payer: Cash Price	$1,146.40
Rate for Payer: Cash Price	$1,146.40
Rate for Payer: Meridian Medicaid	$963.22
Rate for Payer: Priority Health Choice Medicaid	$917.35
Rate for Payer: Priority Health Cigna Priority Health	$1,003.10
Rate for Payer: UMR Bronson Commercial	$659.18

PR SLCTV CATH 1STORD W/WO ART PUNCT/FLUORO/S&I UN

Professional

Both

$504.00

Service Code	HCPCS 36251
Min. Negotiated Rate	$158.90
Max. Negotiated Rate	$555.24
Rate for Payer: Aetna Commercial	$344.70
Rate for Payer: BCBS Complete	$166.84
Rate for Payer: BCBS Trust/PPO	$555.24
Rate for Payer: Cash Price	$403.20
Rate for Payer: Cash Price	$403.20
Rate for Payer: Meridian Medicaid	$166.84
Rate for Payer: Priority Health Choice Medicaid	$158.90
Rate for Payer: Priority Health Cigna Priority Health	$352.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$397.91
Rate for Payer: Priority Health Narrow Network	$397.91
Rate for Payer: Priority Health SBD	$397.91
Rate for Payer: UMR Bronson Commercial	$231.84

PR SLCTV CATH 1STORD W/WO ART PUNCT/FLUOR/S&I BIL

Professional

Both

$656.00

Service Code	HCPCS 36252
Min. Negotiated Rate	$222.16
Max. Negotiated Rate	$787.70
Rate for Payer: Aetna Commercial	$481.35
Rate for Payer: BCBS Complete	$233.27
Rate for Payer: BCBS Trust/PPO	$787.70
Rate for Payer: Cash Price	$524.80
Rate for Payer: Cash Price	$524.80
Rate for Payer: Meridian Medicaid	$233.27
Rate for Payer: Priority Health Choice Medicaid	$222.16
Rate for Payer: Priority Health Cigna Priority Health	$459.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$553.24
Rate for Payer: Priority Health Narrow Network	$553.24
Rate for Payer: Priority Health SBD	$553.24
Rate for Payer: UMR Bronson Commercial	$301.76

PR SLCTV CATH CAROTID/INNOM ART ANGIO INTRCRANL ART

Professional

Both

$1,766.00

Service Code	HCPCS 36223
Min. Negotiated Rate	$207.25
Max. Negotiated Rate	$1,236.20
Rate for Payer: Aetna Commercial	$429.37
Rate for Payer: BCBS Complete	$217.61
Rate for Payer: BCBS Trust/PPO	$927.17
Rate for Payer: Cash Price	$1,412.80
Rate for Payer: Cash Price	$1,412.80
Rate for Payer: Meridian Medicaid	$217.61
Rate for Payer: Priority Health Choice Medicaid	$207.25
Rate for Payer: Priority Health Cigna Priority Health	$1,236.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$511.74
Rate for Payer: Priority Health Narrow Network	$511.74
Rate for Payer: Priority Health SBD	$511.74
Rate for Payer: UMR Bronson Commercial	$812.36

PR SLCTV CATH CAROTID/INNOM ART ANGIO XTRCRANL ART

Professional

Both

$1,623.00

Service Code	HCPCS 36222
Min. Negotiated Rate	$179.35
Max. Negotiated Rate	$1,136.10
Rate for Payer: Aetna Commercial	$380.48
Rate for Payer: BCBS Complete	$188.32
Rate for Payer: BCBS Trust/PPO	$470.19
Rate for Payer: Cash Price	$1,298.40
Rate for Payer: Cash Price	$1,298.40
Rate for Payer: Meridian Medicaid	$188.32
Rate for Payer: Priority Health Choice Medicaid	$179.35
Rate for Payer: Priority Health Cigna Priority Health	$1,136.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$444.19
Rate for Payer: Priority Health Narrow Network	$444.19
Rate for Payer: Priority Health SBD	$444.19
Rate for Payer: UMR Bronson Commercial	$746.58

PR SLCTV CATHETER PLMT LEFT/RIGHT PULMONARY ARTERY

Professional

Both

$989.00

Service Code	HCPCS 36014
Min. Negotiated Rate	$93.93
Max. Negotiated Rate	$1,081.43
Rate for Payer: Aetna Commercial	$203.35
Rate for Payer: BCBS Complete	$98.63
Rate for Payer: BCBS Trust/PPO	$1,081.43
Rate for Payer: Cash Price	$791.20
Rate for Payer: Cash Price	$791.20
Rate for Payer: Meridian Medicaid	$98.63
Rate for Payer: Priority Health Choice Medicaid	$93.93
Rate for Payer: Priority Health Cigna Priority Health	$692.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$235.12
Rate for Payer: Priority Health Narrow Network	$235.12
Rate for Payer: Priority Health SBD	$235.12
Rate for Payer: UMR Bronson Commercial	$454.94

Know your out-of-pocket cost for care.

All Charges