Bronson Methodist Hospital

All Charges

Charge

Type

Setting

Price

PR STRAPPING TOES

Professional

Both

$58.00

Service Code	HCPCS 29550
Min. Negotiated Rate	$7.03
Max. Negotiated Rate	$958.34
Rate for Payer: Aetna Commercial	$15.27
Rate for Payer: BCBS Complete	$7.38
Rate for Payer: BCBS Trust/PPO	$958.34
Rate for Payer: Cash Price	$46.40
Rate for Payer: Cash Price	$46.40
Rate for Payer: Meridian Medicaid	$7.38
Rate for Payer: Priority Health Choice Medicaid	$7.03
Rate for Payer: Priority Health Cigna Priority Health	$40.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$16.85
Rate for Payer: Priority Health Narrow Network	$16.85
Rate for Payer: Priority Health SBD	$16.85
Rate for Payer: UMR Bronson Commercial	$26.68

PR STRAPPING UNNA BOOT

Professional

Both

$93.00

Service Code	HCPCS 29580
Min. Negotiated Rate	$16.61
Max. Negotiated Rate	$1,192.37
Rate for Payer: Aetna Commercial	$35.54
Rate for Payer: BCBS Complete	$17.44
Rate for Payer: BCBS Trust/PPO	$1,192.37
Rate for Payer: Cash Price	$74.40
Rate for Payer: Cash Price	$74.40
Rate for Payer: Meridian Medicaid	$17.44
Rate for Payer: Priority Health Choice Medicaid	$16.61
Rate for Payer: Priority Health Cigna Priority Health	$65.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$39.83
Rate for Payer: Priority Health Narrow Network	$39.83
Rate for Payer: Priority Health SBD	$39.83
Rate for Payer: UMR Bronson Commercial	$42.78

PR STRTCTC BX ASPIR/EXC BURR ICRA LESION W/CT&I/MR

Professional

Both

$6,896.00

Service Code	HCPCS 61751
Min. Negotiated Rate	$741.20
Max. Negotiated Rate	$4,827.20
Rate for Payer: Aetna Commercial	$1,786.62
Rate for Payer: BCBS Complete	$949.17
Rate for Payer: BCBS Trust/PPO	$741.20
Rate for Payer: Cash Price	$5,516.80
Rate for Payer: Cash Price	$5,516.80
Rate for Payer: Meridian Medicaid	$949.17
Rate for Payer: Priority Health Choice Medicaid	$903.97
Rate for Payer: Priority Health Cigna Priority Health	$4,827.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,378.13
Rate for Payer: Priority Health Narrow Network	$2,378.13
Rate for Payer: Priority Health SBD	$2,378.13
Rate for Payer: UMR Bronson Commercial	$3,172.16

PR STRTCTC CPTR ASSTD PX CRANIAL INTRADURAL

Professional

Both

$728.00

Service Code	HCPCS 61781
Min. Negotiated Rate	$150.80
Max. Negotiated Rate	$698.41
Rate for Payer: Aetna Commercial	$305.80
Rate for Payer: BCBS Complete	$158.34
Rate for Payer: BCBS Trust/PPO	$698.41
Rate for Payer: Cash Price	$582.40
Rate for Payer: Cash Price	$582.40
Rate for Payer: Meridian Medicaid	$158.34
Rate for Payer: Priority Health Choice Medicaid	$150.80
Rate for Payer: Priority Health Cigna Priority Health	$509.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$399.75
Rate for Payer: Priority Health Narrow Network	$399.75
Rate for Payer: Priority Health SBD	$399.75
Rate for Payer: UMR Bronson Commercial	$334.88

PR STRTCTC CPTR ASSTD PX EXTRADURAL CRANIAL

Professional

Both

$728.00

Service Code	HCPCS 61782
Min. Negotiated Rate	$109.27
Max. Negotiated Rate	$892.30
Rate for Payer: Aetna Commercial	$222.50
Rate for Payer: BCBS Complete	$114.73
Rate for Payer: BCBS Trust/PPO	$892.30
Rate for Payer: Cash Price	$582.40
Rate for Payer: Cash Price	$582.40
Rate for Payer: Meridian Medicaid	$114.73
Rate for Payer: Priority Health Choice Medicaid	$109.27
Rate for Payer: Priority Health Cigna Priority Health	$509.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$291.04
Rate for Payer: Priority Health Narrow Network	$291.04
Rate for Payer: Priority Health SBD	$291.04
Rate for Payer: UMR Bronson Commercial	$334.88

PR STRTCTC RADIOSURGERY EA ADDL CRANIAL LES COMPLEX

Professional

Both

$8,153.00

Service Code	HCPCS 61799
Min. Negotiated Rate	$194.26
Max. Negotiated Rate	$5,707.10
Rate for Payer: Aetna Commercial	$391.39
Rate for Payer: BCBS Complete	$203.97
Rate for Payer: BCBS Trust/PPO	$1,112.60
Rate for Payer: Cash Price	$6,522.40
Rate for Payer: Cash Price	$6,522.40
Rate for Payer: Meridian Medicaid	$203.97
Rate for Payer: Priority Health Choice Medicaid	$194.26
Rate for Payer: Priority Health Cigna Priority Health	$5,707.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$512.43
Rate for Payer: Priority Health Narrow Network	$512.43
Rate for Payer: Priority Health SBD	$512.43
Rate for Payer: UMR Bronson Commercial	$3,750.38

PR STRTCTC RADIOSURGERY EA ADDL CRANIAL LES SIMPLE

Professional

Both

$8,153.00

Service Code	HCPCS 61797
Min. Negotiated Rate	$140.58
Max. Negotiated Rate	$5,707.10
Rate for Payer: Aetna Commercial	$284.57
Rate for Payer: BCBS Complete	$147.61
Rate for Payer: BCBS Trust/PPO	$828.37
Rate for Payer: Cash Price	$6,522.40
Rate for Payer: Cash Price	$6,522.40
Rate for Payer: Meridian Medicaid	$147.61
Rate for Payer: Priority Health Choice Medicaid	$140.58
Rate for Payer: Priority Health Cigna Priority Health	$5,707.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$370.31
Rate for Payer: Priority Health Narrow Network	$370.31
Rate for Payer: Priority Health SBD	$370.31
Rate for Payer: UMR Bronson Commercial	$3,750.38

PR SUBCUTANEOUS HORMONE PELLET IMPLANTATION

Professional

Both

$178.00

Service Code	HCPCS 11980
Min. Negotiated Rate	$28.95
Max. Negotiated Rate	$124.60
Rate for Payer: Aetna Commercial	$61.12
Rate for Payer: BCBS Complete	$36.91
Rate for Payer: BCBS Trust/PPO	$28.95
Rate for Payer: Cash Price	$142.40
Rate for Payer: Cash Price	$142.40
Rate for Payer: Meridian Medicaid	$36.91
Rate for Payer: Priority Health Choice Medicaid	$35.15
Rate for Payer: Priority Health Cigna Priority Health	$124.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$68.23
Rate for Payer: Priority Health Narrow Network	$68.23
Rate for Payer: Priority Health SBD	$68.23
Rate for Payer: UMR Bronson Commercial	$81.88

PR SUBDURAL TAP FONTANELLE/SUTUR INFANT UNI/BI INIT

Professional

Both

$457.00

Service Code	HCPCS 61000
Min. Negotiated Rate	$73.49
Max. Negotiated Rate	$461.73
Rate for Payer: Aetna Commercial	$145.81
Rate for Payer: BCBS Complete	$77.16
Rate for Payer: BCBS Trust/PPO	$461.73
Rate for Payer: Cash Price	$365.60
Rate for Payer: Cash Price	$365.60
Rate for Payer: Meridian Medicaid	$77.16
Rate for Payer: Priority Health Choice Medicaid	$73.49
Rate for Payer: Priority Health Cigna Priority Health	$319.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$193.09
Rate for Payer: Priority Health Narrow Network	$193.09
Rate for Payer: Priority Health SBD	$193.09
Rate for Payer: UMR Bronson Commercial	$210.22

PR SUB GRFT F/S/N/H/F/G/M/D >/= 100SCM 1ST 100SQ CM

Professional

Both

$481.00

Service Code	HCPCS 15277
Min. Negotiated Rate	$33.96
Max. Negotiated Rate	$336.70
Rate for Payer: Aetna Commercial	$245.92
Rate for Payer: BCBS Complete	$147.83
Rate for Payer: BCBS Trust/PPO	$33.96
Rate for Payer: Cash Price	$384.80
Rate for Payer: Cash Price	$384.80
Rate for Payer: Meridian Medicaid	$147.83
Rate for Payer: Priority Health Choice Medicaid	$140.79
Rate for Payer: Priority Health Cigna Priority Health	$336.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$273.34
Rate for Payer: Priority Health Narrow Network	$273.34
Rate for Payer: Priority Health SBD	$273.34
Rate for Payer: UMR Bronson Commercial	$221.26

PR SUB GRFT F/S/N/H/F/G/M/D >/= 100SCM ADL 100SQ CM

Professional

Both

$126.00

Service Code	HCPCS 15278
Min. Negotiated Rate	$13.97
Max. Negotiated Rate	$88.20
Rate for Payer: Aetna Commercial	$61.98
Rate for Payer: BCBS Complete	$36.91
Rate for Payer: BCBS Trust/PPO	$13.97
Rate for Payer: Cash Price	$100.80
Rate for Payer: Cash Price	$100.80
Rate for Payer: Meridian Medicaid	$36.91
Rate for Payer: Priority Health Choice Medicaid	$35.15
Rate for Payer: Priority Health Cigna Priority Health	$88.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$67.82
Rate for Payer: Priority Health Narrow Network	$67.82
Rate for Payer: Priority Health SBD	$67.82
Rate for Payer: UMR Bronson Commercial	$57.96

PR SUB GRFT F/S/N/H/F/G/M/D <100SQ CM 1ST 25 SQ CM

Professional

Both

$277.00

Service Code	HCPCS 15275
Min. Negotiated Rate	$33.96
Max. Negotiated Rate	$193.90
Rate for Payer: Aetna Commercial	$102.56
Rate for Payer: BCBS Complete	$61.95
Rate for Payer: BCBS Trust/PPO	$33.96
Rate for Payer: Cash Price	$221.60
Rate for Payer: Cash Price	$221.60
Rate for Payer: Meridian Medicaid	$61.95
Rate for Payer: Priority Health Choice Medicaid	$59.00
Rate for Payer: Priority Health Cigna Priority Health	$193.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$113.04
Rate for Payer: Priority Health Narrow Network	$113.04
Rate for Payer: Priority Health SBD	$113.04
Rate for Payer: UMR Bronson Commercial	$127.42

PR SUB GRFT F/S/N/H/F/G/M/D<100SQ CM EA ADDL25SQ CM

Professional

Both

$65.00

Service Code	HCPCS 15276
Min. Negotiated Rate	$15.76
Max. Negotiated Rate	$590.36
Rate for Payer: Aetna Commercial	$27.39
Rate for Payer: BCBS Complete	$16.55
Rate for Payer: BCBS Trust/PPO	$590.36
Rate for Payer: Cash Price	$52.00
Rate for Payer: Cash Price	$52.00
Rate for Payer: Meridian Medicaid	$16.55
Rate for Payer: Priority Health Choice Medicaid	$15.76
Rate for Payer: Priority Health Cigna Priority Health	$45.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$30.42
Rate for Payer: Priority Health Narrow Network	$30.42
Rate for Payer: Priority Health SBD	$30.42
Rate for Payer: UMR Bronson Commercial	$29.90

PR SUBMUCOSAL ABLTJ TONGUE RF 1/> SITES PR SESSION

Professional

Both

$720.00

Service Code	HCPCS 41530
Min. Negotiated Rate	$241.54
Max. Negotiated Rate	$901.28
Rate for Payer: Aetna Commercial	$504.96
Rate for Payer: BCBS Complete	$253.62
Rate for Payer: BCBS Trust/PPO	$901.28
Rate for Payer: Cash Price	$576.00
Rate for Payer: Cash Price	$576.00
Rate for Payer: Meridian Medicaid	$253.62
Rate for Payer: Priority Health Choice Medicaid	$241.54
Rate for Payer: Priority Health Cigna Priority Health	$504.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$667.94
Rate for Payer: Priority Health Narrow Network	$667.94
Rate for Payer: Priority Health SBD	$667.94
Rate for Payer: UMR Bronson Commercial	$331.20

PR SUBMUCOUS RESCJ INFERIOR TURBINATE PRTL/COMPL

Professional

Both

$1,123.00

Service Code	HCPCS 30140
Min. Negotiated Rate	$113.53
Max. Negotiated Rate	$855.85
Rate for Payer: Aetna Commercial	$227.50
Rate for Payer: BCBS Complete	$119.21
Rate for Payer: BCBS Trust/PPO	$855.85
Rate for Payer: Cash Price	$898.40
Rate for Payer: Cash Price	$898.40
Rate for Payer: Meridian Medicaid	$119.21
Rate for Payer: Priority Health Choice Medicaid	$113.53
Rate for Payer: Priority Health Cigna Priority Health	$786.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$246.34
Rate for Payer: Priority Health Narrow Network	$246.34
Rate for Payer: Priority Health SBD	$246.34
Rate for Payer: UMR Bronson Commercial	$516.58

PR SUBQ HOSPITAL CARE PER DAY E/M NORMAL NEWBORN

Professional

Both

$155.00

Service Code	HCPCS 99462
Min. Negotiated Rate	$25.77
Max. Negotiated Rate	$1,469.20
Rate for Payer: Aetna Commercial	$40.96
Rate for Payer: BCBS Complete	$27.06
Rate for Payer: BCBS Trust/PPO	$1,469.20
Rate for Payer: Cash Price	$124.00
Rate for Payer: Cash Price	$124.00
Rate for Payer: Meridian Medicaid	$27.06
Rate for Payer: Priority Health Choice Medicaid	$25.77
Rate for Payer: Priority Health Cigna Priority Health	$108.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$51.82
Rate for Payer: Priority Health Narrow Network	$51.82
Rate for Payer: Priority Health SBD	$51.82
Rate for Payer: UMR Bronson Commercial	$71.30

PR SUBQ I/P CRITICAL CARE PR DAY AGE 28 DAYS/<

Professional

Both

$777.00

Service Code	HCPCS 99469
Min. Negotiated Rate	$250.94
Max. Negotiated Rate	$570.02
Rate for Payer: Aetna Commercial	$390.36
Rate for Payer: BCBS Complete	$381.08
Rate for Payer: BCBS Trust/PPO	$250.94
Rate for Payer: Cash Price	$621.60
Rate for Payer: Cash Price	$621.60
Rate for Payer: Meridian Medicaid	$381.08
Rate for Payer: Priority Health Choice Medicaid	$362.93
Rate for Payer: Priority Health Cigna Priority Health	$543.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$570.02
Rate for Payer: Priority Health Narrow Network	$570.02
Rate for Payer: Priority Health SBD	$570.02
Rate for Payer: UMR Bronson Commercial	$357.42

PR SUBSEQUENT INJECTION, PLATELET RICH PLASMA, ANY SITE, INCLUDING IMAGE GUIDANCE, HARVESTING AND PREPARATION WHEN PERFORMED

Professional

Both

$300.00

Service Code	HCPCS 00672
Hospital Revenue Code	990
Min. Negotiated Rate	$120.00
Max. Negotiated Rate	$210.00
Rate for Payer: BCBS Complete	$120.00
Rate for Payer: Cash Price	$240.00
Rate for Payer: Priority Health Cigna Priority Health	$210.00
Rate for Payer: UMR Bronson Commercial	$138.00

PR SUBSEQUENT INTENSIVE CARE INFANT 1500-2500 GRAMS

Professional

Both

$375.00

Service Code	HCPCS 99479
Min. Negotiated Rate	$113.79
Max. Negotiated Rate	$262.50
Rate for Payer: Aetna Commercial	$122.20
Rate for Payer: BCBS Complete	$119.48
Rate for Payer: BCBS Trust/PPO	$233.51
Rate for Payer: Cash Price	$300.00
Rate for Payer: Cash Price	$300.00
Rate for Payer: Meridian Medicaid	$119.48
Rate for Payer: Priority Health Choice Medicaid	$113.79
Rate for Payer: Priority Health Cigna Priority Health	$262.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$153.77
Rate for Payer: Priority Health Narrow Network	$153.77
Rate for Payer: Priority Health SBD	$153.77
Rate for Payer: UMR Bronson Commercial	$172.50

PR SUBSEQUENT INTENSIVE CARE INFANT < 1500 GRAMS

Professional

Both

$275.00

Service Code	HCPCS 99478
Min. Negotiated Rate	$125.22
Max. Negotiated Rate	$192.50
Rate for Payer: Aetna Commercial	$134.24
Rate for Payer: BCBS Complete	$131.48
Rate for Payer: BCBS Trust/PPO	$188.05
Rate for Payer: Cash Price	$220.00
Rate for Payer: Cash Price	$220.00
Rate for Payer: Meridian Medicaid	$131.48
Rate for Payer: Priority Health Choice Medicaid	$125.22
Rate for Payer: Priority Health Cigna Priority Health	$192.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$168.76
Rate for Payer: Priority Health Narrow Network	$168.76
Rate for Payer: Priority Health SBD	$168.76
Rate for Payer: UMR Bronson Commercial	$126.50

PR SUBSEQUENT INTENSIVE CARE INFANT 2501-5000 GRAMS

Professional

Both

$375.00

Service Code	HCPCS 99480
Min. Negotiated Rate	$109.40
Max. Negotiated Rate	$471.24
Rate for Payer: Aetna Commercial	$117.37
Rate for Payer: BCBS Complete	$114.87
Rate for Payer: BCBS Trust/PPO	$471.24
Rate for Payer: Cash Price	$300.00
Rate for Payer: Cash Price	$300.00
Rate for Payer: Meridian Medicaid	$114.87
Rate for Payer: Priority Health Choice Medicaid	$109.40
Rate for Payer: Priority Health Cigna Priority Health	$262.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$148.20
Rate for Payer: Priority Health Narrow Network	$148.20
Rate for Payer: Priority Health SBD	$148.20
Rate for Payer: UMR Bronson Commercial	$172.50

PR SUBSEQUENT PED CRITICAL CARE 2 THRU 5 YEARS

Professional

Both

$920.00

Service Code	HCPCS 99476
Min. Negotiated Rate	$139.66
Max. Negotiated Rate	$644.00
Rate for Payer: Aetna Commercial	$338.56
Rate for Payer: BCBS Complete	$331.55
Rate for Payer: BCBS Trust/PPO	$139.66
Rate for Payer: Cash Price	$736.00
Rate for Payer: Cash Price	$736.00
Rate for Payer: Meridian Medicaid	$331.55
Rate for Payer: Priority Health Choice Medicaid	$315.76
Rate for Payer: Priority Health Cigna Priority Health	$644.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$425.32
Rate for Payer: Priority Health Narrow Network	$425.32
Rate for Payer: Priority Health SBD	$425.32
Rate for Payer: UMR Bronson Commercial	$423.20

PR SUBSQ PED CRITICAL CARE 29 DAYS THRU 24 MO

Professional

Both

$709.00

Service Code	HCPCS 99472
Min. Negotiated Rate	$67.62
Max. Negotiated Rate	$590.46
Rate for Payer: Aetna Commercial	$397.47
Rate for Payer: BCBS Complete	$391.38
Rate for Payer: BCBS Trust/PPO	$67.62
Rate for Payer: Cash Price	$567.20
Rate for Payer: Cash Price	$567.20
Rate for Payer: Meridian Medicaid	$391.38
Rate for Payer: Priority Health Choice Medicaid	$372.74
Rate for Payer: Priority Health Cigna Priority Health	$496.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$590.46
Rate for Payer: Priority Health Narrow Network	$590.46
Rate for Payer: Priority Health SBD	$590.46
Rate for Payer: UMR Bronson Commercial	$326.14

PR SUBTEMPORAL CRANIAL DECOMPRESSION

Professional

Both

$4,153.00

Service Code	HCPCS 61340
Min. Negotiated Rate	$470.19
Max. Negotiated Rate	$2,907.10
Rate for Payer: Aetna Commercial	$1,861.73
Rate for Payer: BCBS Complete	$983.39
Rate for Payer: BCBS Trust/PPO	$470.19
Rate for Payer: Cash Price	$3,322.40
Rate for Payer: Cash Price	$3,322.40
Rate for Payer: Meridian Medicaid	$983.39
Rate for Payer: Priority Health Choice Medicaid	$936.56
Rate for Payer: Priority Health Cigna Priority Health	$2,907.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,467.04
Rate for Payer: Priority Health Narrow Network	$2,467.04
Rate for Payer: Priority Health SBD	$2,467.04
Rate for Payer: UMR Bronson Commercial	$1,910.38

PR SUCTION ASSISTED LIPECTOMY HEAD & NECK

Professional

Both

$2,000.00

Service Code	HCPCS 15876
Min. Negotiated Rate	$217.36
Max. Negotiated Rate	$1,400.00
Rate for Payer: Aetna Commercial	$367.50
Rate for Payer: BCBS Complete	$538.54
Rate for Payer: BCBS Trust/PPO	$438.68
Rate for Payer: Cash Price	$1,600.00
Rate for Payer: Cash Price	$1,600.00
Rate for Payer: Meridian Medicaid	$538.54
Rate for Payer: Priority Health Choice Medicaid	$512.90
Rate for Payer: Priority Health Cigna Priority Health	$1,400.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$217.36
Rate for Payer: Priority Health Narrow Network	$217.36
Rate for Payer: Priority Health SBD	$217.36
Rate for Payer: UMR Bronson Commercial	$920.00

Know your out-of-pocket cost for care.

All Charges