Bronson Methodist Hospital

All Charges

Charge

Type

Setting

Price

PR SMPL RPR SCALP/NECK/AX/GENIT/TRUNK 12.6-20.0CM

Professional

Both

$562.00

Service Code	HCPCS 12005
Min. Negotiated Rate	$60.28
Max. Negotiated Rate	$561.29
Rate for Payer: Aetna Commercial	$105.98
Rate for Payer: BCBS Complete	$63.29
Rate for Payer: BCBS Trust/PPO	$561.29
Rate for Payer: Cash Price	$449.60
Rate for Payer: Cash Price	$449.60
Rate for Payer: Meridian Medicaid	$63.29
Rate for Payer: Priority Health Choice Medicaid	$60.28
Rate for Payer: Priority Health Cigna Priority Health	$393.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$115.50
Rate for Payer: Priority Health Narrow Network	$115.50
Rate for Payer: Priority Health SBD	$115.50
Rate for Payer: UMR Bronson Commercial	$258.52

PR SMPL RPR SCALP/NECK/AX/GENIT/TRUNK 20.1-30.0CM

Professional

Both

$717.00

Service Code	HCPCS 12006
Min. Negotiated Rate	$73.70
Max. Negotiated Rate	$525.42
Rate for Payer: Aetna Commercial	$129.27
Rate for Payer: BCBS Complete	$77.38
Rate for Payer: BCBS Trust/PPO	$525.42
Rate for Payer: Cash Price	$573.60
Rate for Payer: Cash Price	$573.60
Rate for Payer: Meridian Medicaid	$77.38
Rate for Payer: Priority Health Choice Medicaid	$73.70
Rate for Payer: Priority Health Cigna Priority Health	$501.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$142.22
Rate for Payer: Priority Health Narrow Network	$142.22
Rate for Payer: Priority Health SBD	$142.22
Rate for Payer: UMR Bronson Commercial	$329.82

PR SO 8 ABD RESTRAINT PRE OTS

Professional

Both

$68.00

Service Code	HCPCS L3650
Min. Negotiated Rate	$27.20
Max. Negotiated Rate	$47.60
Rate for Payer: Aetna Commercial	$39.50
Rate for Payer: BCBS Complete	$27.20
Rate for Payer: Cash Price	$54.40
Rate for Payer: Cash Price	$54.40
Rate for Payer: Priority Health Cigna Priority Health	$47.60
Rate for Payer: UMR Bronson Commercial	$31.28

PR SPECIAL CASTING MATERIAL

Professional

Both

$75.00

Service Code	HCPCS A4590
Min. Negotiated Rate	$19.84
Max. Negotiated Rate	$52.50
Rate for Payer: Aetna Commercial	$19.84
Rate for Payer: BCBS Complete	$30.00
Rate for Payer: Cash Price	$60.00
Rate for Payer: Cash Price	$60.00
Rate for Payer: Priority Health Cigna Priority Health	$52.50
Rate for Payer: UMR Bronson Commercial	$34.50

PR SPEECH AUDIOMETRY THRESHOLD

Professional

Both

$40.00

Service Code	HCPCS 92555
Min. Negotiated Rate	$16.00
Max. Negotiated Rate	$1,605.50
Rate for Payer: Aetna Commercial	$25.66
Rate for Payer: BCBS Complete	$16.00
Rate for Payer: BCBS Trust/PPO	$1,605.50
Rate for Payer: Cash Price	$32.00
Rate for Payer: Cash Price	$32.00
Rate for Payer: Priority Health Cigna Priority Health	$28.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$36.83
Rate for Payer: Priority Health Narrow Network	$36.83
Rate for Payer: Priority Health SBD	$36.83
Rate for Payer: UMR Bronson Commercial	$18.40

PR SPEECH AUDIOMETRY THRESHOLD SPEECH RECOGNIJ

Professional

Both

$65.00

Service Code	HCPCS 92556
Min. Negotiated Rate	$26.00
Max. Negotiated Rate	$1,742.33
Rate for Payer: Aetna Commercial	$40.61
Rate for Payer: BCBS Complete	$26.00
Rate for Payer: BCBS Trust/PPO	$1,742.33
Rate for Payer: Cash Price	$52.00
Rate for Payer: Cash Price	$52.00
Rate for Payer: Priority Health Cigna Priority Health	$45.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$57.05
Rate for Payer: Priority Health Narrow Network	$57.05
Rate for Payer: Priority Health SBD	$57.05
Rate for Payer: UMR Bronson Commercial	$29.90

PR SPHINCTEROTOMY ANAL DIVISION SPHINCTER SPX

Professional

Both

$882.00

Service Code	HCPCS 46080
Min. Negotiated Rate	$101.18
Max. Negotiated Rate	$1,543.16
Rate for Payer: Aetna Commercial	$211.65
Rate for Payer: BCBS Complete	$106.24
Rate for Payer: BCBS Trust/PPO	$1,543.16
Rate for Payer: Cash Price	$705.60
Rate for Payer: Cash Price	$705.60
Rate for Payer: Meridian Medicaid	$106.24
Rate for Payer: Priority Health Choice Medicaid	$101.18
Rate for Payer: Priority Health Cigna Priority Health	$617.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$278.71
Rate for Payer: Priority Health Narrow Network	$278.71
Rate for Payer: Priority Health SBD	$278.71
Rate for Payer: UMR Bronson Commercial	$405.72

PR SPHNCTROP ANAL INCONTINENCE/PROLAPSE ADULT

Professional

Both

$1,480.00

Service Code	HCPCS 46750
Min. Negotiated Rate	$479.04
Max. Negotiated Rate	$1,315.89
Rate for Payer: Aetna Commercial	$1,008.35
Rate for Payer: BCBS Complete	$502.99
Rate for Payer: BCBS Trust/PPO	$714.79
Rate for Payer: Cash Price	$1,184.00
Rate for Payer: Cash Price	$1,184.00
Rate for Payer: Meridian Medicaid	$502.99
Rate for Payer: Priority Health Choice Medicaid	$479.04
Rate for Payer: Priority Health Cigna Priority Health	$1,036.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,315.89
Rate for Payer: Priority Health Narrow Network	$1,315.89
Rate for Payer: Priority Health SBD	$1,315.89
Rate for Payer: UMR Bronson Commercial	$680.80

PR SPHNCTROP ANAL INCONTINENCE/PROLAPSE CHLD

Professional

Both

$1,275.00

Service Code	HCPCS 46751
Min. Negotiated Rate	$430.47
Max. Negotiated Rate	$1,183.59
Rate for Payer: Aetna Commercial	$898.95
Rate for Payer: BCBS Complete	$451.99
Rate for Payer: BCBS Trust/PPO	$477.58
Rate for Payer: Cash Price	$1,020.00
Rate for Payer: Cash Price	$1,020.00
Rate for Payer: Meridian Medicaid	$451.99
Rate for Payer: Priority Health Choice Medicaid	$430.47
Rate for Payer: Priority Health Cigna Priority Health	$892.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,183.59
Rate for Payer: Priority Health Narrow Network	$1,183.59
Rate for Payer: Priority Health SBD	$1,183.59
Rate for Payer: UMR Bronson Commercial	$586.50

PR SPHNCTROP ANAL LEVATOR MUSC IMBRCJ

Professional

Both

$1,851.00

Service Code	HCPCS 46761
Min. Negotiated Rate	$582.98
Max. Negotiated Rate	$1,606.34
Rate for Payer: Aetna Commercial	$1,233.15
Rate for Payer: BCBS Complete	$612.13
Rate for Payer: BCBS Trust/PPO	$1,041.81
Rate for Payer: Cash Price	$1,480.80
Rate for Payer: Cash Price	$1,480.80
Rate for Payer: Meridian Medicaid	$612.13
Rate for Payer: Priority Health Choice Medicaid	$582.98
Rate for Payer: Priority Health Cigna Priority Health	$1,295.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,606.34
Rate for Payer: Priority Health Narrow Network	$1,606.34
Rate for Payer: Priority Health SBD	$1,606.34
Rate for Payer: UMR Bronson Commercial	$851.46

PR SPLENC TOT EN BLOC EXTNSV DS CONJUNCT W/OTH PX

Professional

Both

$2,644.00

Service Code	HCPCS 38102
Min. Negotiated Rate	$165.93
Max. Negotiated Rate	$1,850.80
Rate for Payer: Aetna Commercial	$326.41
Rate for Payer: BCBS Complete	$174.23
Rate for Payer: BCBS Trust/PPO	$538.34
Rate for Payer: Cash Price	$2,115.20
Rate for Payer: Cash Price	$2,115.20
Rate for Payer: Meridian Medicaid	$174.23
Rate for Payer: Priority Health Choice Medicaid	$165.93
Rate for Payer: Priority Health Cigna Priority Health	$1,850.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$562.81
Rate for Payer: Priority Health Narrow Network	$562.81
Rate for Payer: Priority Health SBD	$562.81
Rate for Payer: UMR Bronson Commercial	$1,216.24

PR SPLENECTOMY PARTIAL SEPARATE PROCEDURE

Professional

Both

$2,938.00

Service Code	HCPCS 38101
Min. Negotiated Rate	$566.87
Max. Negotiated Rate	$2,516.36
Rate for Payer: Aetna Commercial	$1,458.52
Rate for Payer: BCBS Complete	$780.32
Rate for Payer: BCBS Trust/PPO	$566.87
Rate for Payer: Cash Price	$2,350.40
Rate for Payer: Cash Price	$2,350.40
Rate for Payer: Meridian Medicaid	$780.32
Rate for Payer: Priority Health Choice Medicaid	$743.16
Rate for Payer: Priority Health Cigna Priority Health	$2,056.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,516.36
Rate for Payer: Priority Health Narrow Network	$2,516.36
Rate for Payer: Priority Health SBD	$2,516.36
Rate for Payer: UMR Bronson Commercial	$1,351.48

PR SPLENECTOMY TOTAL SEPARATE PROCEDURE

Professional

Both

$4,639.00

Service Code	HCPCS 38100
Min. Negotiated Rate	$482.87
Max. Negotiated Rate	$3,247.30
Rate for Payer: Aetna Commercial	$1,440.33
Rate for Payer: BCBS Complete	$770.48
Rate for Payer: BCBS Trust/PPO	$482.87
Rate for Payer: Cash Price	$3,711.20
Rate for Payer: Cash Price	$3,711.20
Rate for Payer: Meridian Medicaid	$770.48
Rate for Payer: Priority Health Choice Medicaid	$733.79
Rate for Payer: Priority Health Cigna Priority Health	$3,247.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,485.94
Rate for Payer: Priority Health Narrow Network	$2,485.94
Rate for Payer: Priority Health SBD	$2,485.94
Rate for Payer: UMR Bronson Commercial	$2,133.94

PR SPLINT

Professional

Both

$30.00

Service Code	HCPCS A4570
Min. Negotiated Rate	$8.90
Max. Negotiated Rate	$21.00
Rate for Payer: Aetna Commercial	$8.90
Rate for Payer: BCBS Complete	$12.00
Rate for Payer: Cash Price	$24.00
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 SPLIT AGRFT F/S/N/H/F/G/M/D GT 1ST 100 CM/</1 %

Professional

Both

$1,571.00

Service Code	HCPCS 15120
Min. Negotiated Rate	$138.90
Max. Negotiated Rate	$1,099.70
Rate for Payer: Aetna Commercial	$743.74
Rate for Payer: BCBS Complete	$463.63
Rate for Payer: BCBS Trust/PPO	$138.90
Rate for Payer: Cash Price	$1,256.80
Rate for Payer: Cash Price	$1,256.80
Rate for Payer: Meridian Medicaid	$463.63
Rate for Payer: Priority Health Choice Medicaid	$441.55
Rate for Payer: Priority Health Cigna Priority Health	$1,099.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$845.09
Rate for Payer: Priority Health Narrow Network	$845.09
Rate for Payer: Priority Health SBD	$845.09
Rate for Payer: UMR Bronson Commercial	$722.66

PR SPLIT AGRFT F/S/N/H/F/G/M/D GT 1ST 100 CM/</1 %

Professional

Both

$1,571.00

Service Code	HCPCS 15120
Hospital Charge Code	15120
Min. Negotiated Rate	$138.90
Max. Negotiated Rate	$1,099.70
Rate for Payer: Aetna Commercial	$743.74
Rate for Payer: BCBS Complete	$463.63
Rate for Payer: BCBS Trust/PPO	$138.90
Rate for Payer: Cash Price	$1,256.80
Rate for Payer: Cash Price	$1,256.80
Rate for Payer: Meridian Medicaid	$463.63
Rate for Payer: Priority Health Choice Medicaid	$441.55
Rate for Payer: Priority Health Cigna Priority Health	$1,099.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$845.09
Rate for Payer: Priority Health Narrow Network	$845.09
Rate for Payer: Priority Health SBD	$845.09
Rate for Payer: UMR Bronson Commercial	$722.66

PR SPLIT AGRFT F/S/N/H/F/G/M/D GT 1ST 100 CM/</1 %

Facility

$1,571.00

Service Code	CPT 15120
Hospital Charge Code	15120
Hospital Revenue Code	960
Min. Negotiated Rate	$581.27
Max. Negotiated Rate	$10,039.01
Rate for Payer: Aetna American Axle	$1,021.15
Rate for Payer: Aetna Commercial	$1,335.35
Rate for Payer: Aetna Medicare	$3,316.52
Rate for Payer: Aetna New Business (MI Preferred)	$1,021.15
Rate for Payer: Allen County Amish Medical Aid Commercial	$3,986.20
Rate for Payer: Amish Plain Church Group Commercial	$3,986.20
Rate for Payer: BCBS Complete	$1,831.74
Rate for Payer: BCBS MAPPO	$3,188.96
Rate for Payer: BCBS Trust/PPO	$4,575.21
Rate for Payer: BCN Medicare Advantage	$3,188.96
Rate for Payer: Cash Price	$1,256.80
Rate for Payer: Cash Price	$1,256.80
Rate for Payer: Cofinity Commercial	$1,099.70
Rate for Payer: Cofinity Commercial	$1,351.06
Rate for Payer: Encore Health Key Benefits Commercial	$1,256.80
Rate for Payer: Health Alliance Plan Medicare Advantage	$3,188.96
Rate for Payer: Healthscope Commercial	$1,413.90
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial	$1,099.70
Rate for Payer: Lakeland Regional Health Systems Commercial	$1,178.25
Rate for Payer: Mclaren Medicaid	$1,744.36
Rate for Payer: Mclaren Medicare	$3,188.96
Rate for Payer: Meridian Medicaid	$1,831.74
Rate for Payer: Meridian Wellcare - Medicare Advantage	$3,348.41
Rate for Payer: MI Amish Medical Board Commercial	$3,667.30
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1,335.35
Rate for Payer: PACE Medicare	$3,029.51
Rate for Payer: PACE SWMI	$3,188.96
Rate for Payer: PHP Commercial	$1,335.35
Rate for Payer: PHP Medicare Advantage	$3,188.96
Rate for Payer: Priority Health Choice Medicaid	$1,744.36
Rate for Payer: Priority Health Cigna Priority Health	$1,099.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$10,039.01
Rate for Payer: Priority Health Medicare	$3,188.96
Rate for Payer: Priority Health Narrow Network	$8,031.21
Rate for Payer: Priority Health SBD	$989.73
Rate for Payer: Railroad Medicare Medicare	$3,188.96
Rate for Payer: UHC All Payor (Choice/PPO)	$746.67
Rate for Payer: UHC Dual Complete DSNP	$3,188.96
Rate for Payer: UHC Exchange	$678.79
Rate for Payer: UHC Medicare Advantage	$3,284.63
Rate for Payer: UMR Bronson Commercial	$581.27
Rate for Payer: VA VA	$3,188.96
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$1,178.25

PR SPLIT AGRFT F/S/N/H/F/G/M/D GT 1ST 100 CM/</1 %

Facility

$1,571.00

Service Code	CPT 15120
Hospital Charge Code	15120
Hospital Revenue Code	960
Min. Negotiated Rate	$691.24
Max. Negotiated Rate	$1,413.90
Rate for Payer: Aetna American Axle	$1,021.15
Rate for Payer: Aetna Commercial	$1,335.35
Rate for Payer: Aetna New Business (MI Preferred)	$1,021.15
Rate for Payer: Cash Price	$1,256.80
Rate for Payer: Cofinity Commercial	$1,099.70
Rate for Payer: Cofinity Commercial	$1,351.06
Rate for Payer: Encore Health Key Benefits Commercial	$1,256.80
Rate for Payer: Healthscope Commercial	$1,413.90
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial	$1,099.70
Rate for Payer: Lakeland Regional Health Systems Commercial	$1,178.25
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1,335.35
Rate for Payer: PHP Commercial	$1,335.35
Rate for Payer: Priority Health Cigna Priority Health	$1,099.70
Rate for Payer: Priority Health SBD	$989.73
Rate for Payer: UMR Bronson Commercial	$691.24
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$1,178.25

PR SPLIT AGRFT F/S/N/H/F/G/M/D GT EA 100 CM/EA 1 %

Professional

Both

$490.00

Service Code	HCPCS 15121
Min. Negotiated Rate	$83.50
Max. Negotiated Rate	$343.00
Rate for Payer: Aetna Commercial	$147.37
Rate for Payer: BCBS Complete	$87.68
Rate for Payer: BCBS Trust/PPO	$138.90
Rate for Payer: Cash Price	$392.00
Rate for Payer: Cash Price	$392.00
Rate for Payer: Meridian Medicaid	$87.68
Rate for Payer: Priority Health Choice Medicaid	$83.50
Rate for Payer: Priority Health Cigna Priority Health	$343.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$163.18
Rate for Payer: Priority Health Narrow Network	$163.18
Rate for Payer: Priority Health SBD	$163.18
Rate for Payer: UMR Bronson Commercial	$225.40

PR SPLIT AGRFT T/A/L 1ST 100 CM/&/1% BDY INFT/CHLD

Facility

$2,110.00

Service Code	CPT 15100
Hospital Charge Code	15100
Hospital Revenue Code	960
Min. Negotiated Rate	$928.40
Max. Negotiated Rate	$1,899.00
Rate for Payer: Aetna American Axle	$1,371.50
Rate for Payer: Aetna Commercial	$1,793.50
Rate for Payer: Aetna New Business (MI Preferred)	$1,371.50
Rate for Payer: Cash Price	$1,688.00
Rate for Payer: Cofinity Commercial	$1,477.00
Rate for Payer: Cofinity Commercial	$1,814.60
Rate for Payer: Encore Health Key Benefits Commercial	$1,688.00
Rate for Payer: Healthscope Commercial	$1,899.00
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial	$1,477.00
Rate for Payer: Lakeland Regional Health Systems Commercial	$1,582.50
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1,793.50
Rate for Payer: PHP Commercial	$1,793.50
Rate for Payer: Priority Health Cigna Priority Health	$1,477.00
Rate for Payer: Priority Health SBD	$1,329.30
Rate for Payer: UMR Bronson Commercial	$928.40
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$1,582.50

PR SPLIT AGRFT T/A/L 1ST 100 CM/&/1% BDY INFT/CHLD

Facility

$2,110.00

Service Code	CPT 15100
Hospital Charge Code	15100
Hospital Revenue Code	960
Min. Negotiated Rate	$704.33
Max. Negotiated Rate	$5,102.91
Rate for Payer: Aetna American Axle	$1,371.50
Rate for Payer: Aetna Commercial	$1,793.50
Rate for Payer: Aetna Medicare	$1,685.82
Rate for Payer: Aetna New Business (MI Preferred)	$1,371.50
Rate for Payer: Allen County Amish Medical Aid Commercial	$2,026.22
Rate for Payer: Amish Plain Church Group Commercial	$2,026.22
Rate for Payer: BCBS Complete	$931.09
Rate for Payer: BCBS MAPPO	$1,620.98
Rate for Payer: BCBS Trust/PPO	$3,756.53
Rate for Payer: BCN Medicare Advantage	$1,620.98
Rate for Payer: Cash Price	$1,688.00
Rate for Payer: Cash Price	$1,688.00
Rate for Payer: Cofinity Commercial	$1,477.00
Rate for Payer: Cofinity Commercial	$1,814.60
Rate for Payer: Encore Health Key Benefits Commercial	$1,688.00
Rate for Payer: Health Alliance Plan Medicare Advantage	$1,620.98
Rate for Payer: Healthscope Commercial	$1,899.00
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial	$1,477.00
Rate for Payer: Lakeland Regional Health Systems Commercial	$1,582.50
Rate for Payer: Mclaren Medicaid	$886.68
Rate for Payer: Mclaren Medicare	$1,620.98
Rate for Payer: Meridian Medicaid	$931.09
Rate for Payer: Meridian Wellcare - Medicare Advantage	$1,702.03
Rate for Payer: MI Amish Medical Board Commercial	$1,864.13
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1,793.50
Rate for Payer: PACE Medicare	$1,539.93
Rate for Payer: PACE SWMI	$1,620.98
Rate for Payer: PHP Commercial	$1,793.50
Rate for Payer: PHP Medicare Advantage	$1,620.98
Rate for Payer: Priority Health Choice Medicaid	$886.68
Rate for Payer: Priority Health Cigna Priority Health	$1,477.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$5,102.91
Rate for Payer: Priority Health Medicare	$1,620.98
Rate for Payer: Priority Health Narrow Network	$4,082.33
Rate for Payer: Priority Health SBD	$1,329.30
Rate for Payer: Railroad Medicare Medicare	$1,620.98
Rate for Payer: UHC All Payor (Choice/PPO)	$774.76
Rate for Payer: UHC Dual Complete DSNP	$1,620.98
Rate for Payer: UHC Exchange	$704.33
Rate for Payer: UHC Medicare Advantage	$1,669.61
Rate for Payer: UMR Bronson Commercial	$780.70
Rate for Payer: VA VA	$1,620.98
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$1,582.50

PR SPLIT AGRFT T/A/L 1ST 100 CM/&/1% BDY INFT/CHLD

Professional

Both

$2,110.00

Service Code	HCPCS 15100
Hospital Charge Code	15100
Min. Negotiated Rate	$206.12
Max. Negotiated Rate	$1,477.00
Rate for Payer: Aetna Commercial	$770.92
Rate for Payer: BCBS Complete	$481.07
Rate for Payer: BCBS Trust/PPO	$206.12
Rate for Payer: Cash Price	$1,688.00
Rate for Payer: Cash Price	$1,688.00
Rate for Payer: Meridian Medicaid	$481.07
Rate for Payer: Priority Health Choice Medicaid	$458.16
Rate for Payer: Priority Health Cigna Priority Health	$1,477.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$878.80
Rate for Payer: Priority Health Narrow Network	$878.80
Rate for Payer: Priority Health SBD	$878.80
Rate for Payer: UMR Bronson Commercial	$970.60

PR SPLIT AGRFT T/A/L 1ST 100 CM/&/1% BDY INFT/CHLD

Professional

Both

$2,110.00

Service Code	HCPCS 15100
Min. Negotiated Rate	$206.12
Max. Negotiated Rate	$1,477.00
Rate for Payer: Aetna Commercial	$770.92
Rate for Payer: BCBS Complete	$481.07
Rate for Payer: BCBS Trust/PPO	$206.12
Rate for Payer: Cash Price	$1,688.00
Rate for Payer: Cash Price	$1,688.00
Rate for Payer: Meridian Medicaid	$481.07
Rate for Payer: Priority Health Choice Medicaid	$458.16
Rate for Payer: Priority Health Cigna Priority Health	$1,477.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$878.80
Rate for Payer: Priority Health Narrow Network	$878.80
Rate for Payer: Priority Health SBD	$878.80
Rate for Payer: UMR Bronson Commercial	$970.60

PR SPLIT AGRFT T/A/L EA 100 CM/EA 1% BDY INFT/CHLD

Professional

Both

$1,352.00

Service Code	HCPCS 15101
Min. Negotiated Rate	$70.29
Max. Negotiated Rate	$946.40
Rate for Payer: Aetna Commercial	$122.15
Rate for Payer: BCBS Complete	$73.80
Rate for Payer: BCBS Trust/PPO	$206.12
Rate for Payer: Cash Price	$1,081.60
Rate for Payer: Cash Price	$1,081.60
Rate for Payer: Meridian Medicaid	$73.80
Rate for Payer: Priority Health Choice Medicaid	$70.29
Rate for Payer: Priority Health Cigna Priority Health	$946.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$135.23
Rate for Payer: Priority Health Narrow Network	$135.23
Rate for Payer: Priority Health SBD	$135.23
Rate for Payer: UMR Bronson Commercial	$621.92

PR SPMTRY W/VC EXPIRATORY FLO W/WO MXML VOL VNTJ

Professional

Both

$16.00

Service Code	HCPCS 94010
Min. Negotiated Rate	$6.40
Max. Negotiated Rate	$1,259.47
Rate for Payer: Aetna Commercial	$31.26
Rate for Payer: Aetna Commercial	$31.26
Rate for Payer: BCBS Complete	$31.20
Rate for Payer: BCBS Complete	$6.40
Rate for Payer: BCBS Trust/PPO	$1,259.47
Rate for Payer: BCBS Trust/PPO	$1,259.47
Rate for Payer: Cash Price	$62.40
Rate for Payer: Cash Price	$12.80
Rate for Payer: Cash Price	$62.40
Rate for Payer: Cash Price	$12.80
Rate for Payer: Priority Health Cigna Priority Health	$54.60
Rate for Payer: Priority Health Cigna Priority Health	$11.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$10.78
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$10.78
Rate for Payer: Priority Health Narrow Network	$10.78
Rate for Payer: Priority Health Narrow Network	$10.78
Rate for Payer: Priority Health SBD	$35.93
Rate for Payer: Priority Health SBD	$35.93
Rate for Payer: UMR Bronson Commercial	$7.36
Rate for Payer: UMR Bronson Commercial	$35.88

Know your out-of-pocket cost for care.

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