Bronson Methodist Hospital

All Charges

Charge

Type

Setting

Price

PR SUTURE REPAIR AORTA/GREAT VESSEL W/BYPASS

Professional

Both

$5,576.00

Service Code	HCPCS 33322
Min. Negotiated Rate	$484.45
Max. Negotiated Rate	$3,903.20
Rate for Payer: Aetna Commercial	$1,863.91
Rate for Payer: BCBS Complete	$922.78
Rate for Payer: BCBS Trust/PPO	$484.45
Rate for Payer: Cash Price	$4,460.80
Rate for Payer: Cash Price	$4,460.80
Rate for Payer: Meridian Medicaid	$922.78
Rate for Payer: Priority Health Choice Medicaid	$878.84
Rate for Payer: Priority Health Cigna Priority Health	$3,903.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,166.67
Rate for Payer: Priority Health Narrow Network	$2,166.67
Rate for Payer: Priority Health SBD	$2,166.67
Rate for Payer: UMR Bronson Commercial	$2,564.96

PR SUTURE/REPAIR TESTICULAR INJURY

Professional

Both

$1,231.00

Service Code	HCPCS 54670
Min. Negotiated Rate	$262.42
Max. Negotiated Rate	$2,909.88
Rate for Payer: Aetna Commercial	$521.74
Rate for Payer: BCBS Complete	$275.54
Rate for Payer: BCBS Trust/PPO	$2,909.88
Rate for Payer: Cash Price	$984.80
Rate for Payer: Cash Price	$984.80
Rate for Payer: Meridian Medicaid	$275.54
Rate for Payer: Priority Health Choice Medicaid	$262.42
Rate for Payer: Priority Health Cigna Priority Health	$861.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$655.99
Rate for Payer: Priority Health Narrow Network	$655.99
Rate for Payer: Priority Health SBD	$655.99
Rate for Payer: UMR Bronson Commercial	$566.26

PR SUTURE SCIATIC NERVE

Professional

Both

$2,451.00

Service Code	HCPCS 64858
Min. Negotiated Rate	$255.70
Max. Negotiated Rate	$1,988.01
Rate for Payer: Aetna Commercial	$1,514.83
Rate for Payer: BCBS Complete	$790.38
Rate for Payer: BCBS Trust/PPO	$255.70
Rate for Payer: Cash Price	$1,960.80
Rate for Payer: Cash Price	$1,960.80
Rate for Payer: Meridian Medicaid	$790.38
Rate for Payer: Priority Health Choice Medicaid	$752.74
Rate for Payer: Priority Health Cigna Priority Health	$1,715.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,988.01
Rate for Payer: Priority Health Narrow Network	$1,988.01
Rate for Payer: Priority Health SBD	$1,988.01
Rate for Payer: UMR Bronson Commercial	$1,127.46

PR SUTURE TRACHEAL WOUND/INJURY CERVICAL

Professional

Both

$1,558.00

Service Code	HCPCS 31800
Min. Negotiated Rate	$453.48
Max. Negotiated Rate	$1,267.39
Rate for Payer: Aetna Commercial	$913.40
Rate for Payer: BCBS Complete	$476.15
Rate for Payer: BCBS Trust/PPO	$1,267.39
Rate for Payer: Cash Price	$1,246.40
Rate for Payer: Cash Price	$1,246.40
Rate for Payer: Meridian Medicaid	$476.15
Rate for Payer: Priority Health Choice Medicaid	$453.48
Rate for Payer: Priority Health Cigna Priority Health	$1,090.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$990.46
Rate for Payer: Priority Health Narrow Network	$990.46
Rate for Payer: Priority Health SBD	$990.46
Rate for Payer: UMR Bronson Commercial	$716.68

PR SUTURE TRACHEAL WOUND/INJURY INTRATHORACIC

Professional

Both

$1,638.00

Service Code	HCPCS 31805
Min. Negotiated Rate	$518.66
Max. Negotiated Rate	$1,619.77
Rate for Payer: Aetna Commercial	$1,053.39
Rate for Payer: BCBS Complete	$544.59
Rate for Payer: BCBS Trust/PPO	$1,619.77
Rate for Payer: Cash Price	$1,310.40
Rate for Payer: Cash Price	$1,310.40
Rate for Payer: Meridian Medicaid	$544.59
Rate for Payer: Priority Health Choice Medicaid	$518.66
Rate for Payer: Priority Health Cigna Priority Health	$1,146.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,119.64
Rate for Payer: Priority Health Narrow Network	$1,119.64
Rate for Payer: Priority Health SBD	$1,119.64
Rate for Payer: UMR Bronson Commercial	$753.48

PR SVC PRV EMER BASIS IN OFFICE DISRUPTING SVCS

Professional

Both

$56.00

Service Code	HCPCS 99058
Min. Negotiated Rate	$22.40
Max. Negotiated Rate	$773.43
Rate for Payer: Aetna Commercial	$28.30
Rate for Payer: BCBS Complete	$22.40
Rate for Payer: BCBS Trust/PPO	$773.43
Rate for Payer: Cash Price	$44.80
Rate for Payer: Cash Price	$44.80
Rate for Payer: Priority Health Cigna Priority Health	$39.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$28.75
Rate for Payer: Priority Health Narrow Network	$28.75
Rate for Payer: Priority Health SBD	$28.75
Rate for Payer: UMR Bronson Commercial	$25.76

PR SVC PRV OFFICE REG SCHEDD EVN WKEND/HOLIDAY HRS

Professional

Both

$59.00

Service Code	HCPCS 99051
Min. Negotiated Rate	$20.02
Max. Negotiated Rate	$556.30
Rate for Payer: Aetna Commercial	$20.02
Rate for Payer: BCBS Complete	$23.60
Rate for Payer: BCBS Trust/PPO	$556.30
Rate for Payer: Cash Price	$47.20
Rate for Payer: Cash Price	$47.20
Rate for Payer: Priority Health Cigna Priority Health	$41.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$24.25
Rate for Payer: Priority Health Narrow Network	$24.25
Rate for Payer: Priority Health SBD	$24.25
Rate for Payer: UMR Bronson Commercial	$27.14

PR SYMPATHECTOMY CERVICAL

Professional

Both

$1,695.00

Service Code	HCPCS 64802
Min. Negotiated Rate	$206.04
Max. Negotiated Rate	$1,453.49
Rate for Payer: Aetna Commercial	$1,082.29
Rate for Payer: BCBS Complete	$581.27
Rate for Payer: BCBS Trust/PPO	$206.04
Rate for Payer: Cash Price	$1,356.00
Rate for Payer: Cash Price	$1,356.00
Rate for Payer: Meridian Medicaid	$581.27
Rate for Payer: Priority Health Choice Medicaid	$553.59
Rate for Payer: Priority Health Cigna Priority Health	$1,186.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,453.49
Rate for Payer: Priority Health Narrow Network	$1,453.49
Rate for Payer: Priority Health SBD	$1,453.49
Rate for Payer: UMR Bronson Commercial	$779.70

PR SYMPATHECTOMY LUMBAR

Professional

Both

$313.00

Service Code	HCPCS 64818
Min. Negotiated Rate	$143.98
Max. Negotiated Rate	$1,322.69
Rate for Payer: Aetna Commercial	$1,002.38
Rate for Payer: BCBS Complete	$526.03
Rate for Payer: BCBS Trust/PPO	$668.83
Rate for Payer: Cash Price	$250.40
Rate for Payer: Cash Price	$250.40
Rate for Payer: Meridian Medicaid	$526.03
Rate for Payer: Priority Health Choice Medicaid	$500.98
Rate for Payer: Priority Health Cigna Priority Health	$219.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,322.69
Rate for Payer: Priority Health Narrow Network	$1,322.69
Rate for Payer: Priority Health SBD	$1,322.69
Rate for Payer: UMR Bronson Commercial	$143.98

PR SYMPHYSIOTOMY HORSESHOE KDN W/WO PLOP UNI/BI

Professional

Both

$2,125.00

Service Code	HCPCS 50540
Min. Negotiated Rate	$726.33
Max. Negotiated Rate	$2,068.29
Rate for Payer: Aetna Commercial	$1,471.63
Rate for Payer: BCBS Complete	$762.65
Rate for Payer: BCBS Trust/PPO	$2,068.29
Rate for Payer: Cash Price	$1,700.00
Rate for Payer: Cash Price	$1,700.00
Rate for Payer: Meridian Medicaid	$762.65
Rate for Payer: Priority Health Choice Medicaid	$726.33
Rate for Payer: Priority Health Cigna Priority Health	$1,487.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,821.55
Rate for Payer: Priority Health Narrow Network	$1,821.55
Rate for Payer: Priority Health SBD	$1,821.55
Rate for Payer: UMR Bronson Commercial	$977.50

PR SYNDACTYLIZATION TOES

Professional

Both

$835.00

Service Code	HCPCS 28280
Min. Negotiated Rate	$222.37
Max. Negotiated Rate	$756.00
Rate for Payer: Aetna Commercial	$457.50
Rate for Payer: BCBS Complete	$233.49
Rate for Payer: BCBS Trust/PPO	$756.00
Rate for Payer: Cash Price	$668.00
Rate for Payer: Cash Price	$668.00
Rate for Payer: Meridian Medicaid	$233.49
Rate for Payer: Priority Health Choice Medicaid	$222.37
Rate for Payer: Priority Health Cigna Priority Health	$584.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$529.54
Rate for Payer: Priority Health Narrow Network	$529.54
Rate for Payer: Priority Health SBD	$529.54
Rate for Payer: UMR Bronson Commercial	$384.10

PR SYNOVECTOMY EXTENSOR TENDON SHTH WRIST 1 CMPRT

Professional

Both

$1,251.00

Service Code	HCPCS 25118
Min. Negotiated Rate	$145.28
Max. Negotiated Rate	$875.70
Rate for Payer: Aetna Commercial	$506.36
Rate for Payer: BCBS Complete	$263.91
Rate for Payer: BCBS Trust/PPO	$145.28
Rate for Payer: Cash Price	$1,000.80
Rate for Payer: Cash Price	$1,000.80
Rate for Payer: Meridian Medicaid	$263.91
Rate for Payer: Priority Health Choice Medicaid	$251.34
Rate for Payer: Priority Health Cigna Priority Health	$875.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$594.40
Rate for Payer: Priority Health Narrow Network	$594.40
Rate for Payer: Priority Health SBD	$594.40
Rate for Payer: UMR Bronson Commercial	$575.46

PR SYNOVECTOMY METATARSOPHALANGEAL JOINT EACH

Professional

Both

$996.00

Service Code	HCPCS 28072
Min. Negotiated Rate	$210.23
Max. Negotiated Rate	$697.20
Rate for Payer: Aetna Commercial	$423.46
Rate for Payer: BCBS Complete	$220.74
Rate for Payer: BCBS Trust/PPO	$567.39
Rate for Payer: Cash Price	$796.80
Rate for Payer: Cash Price	$796.80
Rate for Payer: Meridian Medicaid	$220.74
Rate for Payer: Priority Health Choice Medicaid	$210.23
Rate for Payer: Priority Health Cigna Priority Health	$697.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$495.34
Rate for Payer: Priority Health Narrow Network	$495.34
Rate for Payer: Priority Health SBD	$495.34
Rate for Payer: UMR Bronson Commercial	$458.16

PR SYNVCT MTCARPHLNGL JT W/INTRNSC RLS&XTNSR HOOD

Professional

Both

$1,692.00

Service Code	HCPCS 26135
Min. Negotiated Rate	$295.85
Max. Negotiated Rate	$1,184.40
Rate for Payer: Aetna Commercial	$736.91
Rate for Payer: BCBS Complete	$378.86
Rate for Payer: BCBS Trust/PPO	$295.85
Rate for Payer: Cash Price	$1,353.60
Rate for Payer: Cash Price	$1,353.60
Rate for Payer: Meridian Medicaid	$378.86
Rate for Payer: Priority Health Choice Medicaid	$360.82
Rate for Payer: Priority Health Cigna Priority Health	$1,184.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$857.88
Rate for Payer: Priority Health Narrow Network	$857.88
Rate for Payer: Priority Health SBD	$857.88
Rate for Payer: UMR Bronson Commercial	$778.32

PR SYNVCT PROX IPHAL JT W/XTNSR RCNSTJ EA IPHAL JT

Professional

Both

$1,447.00

Service Code	HCPCS 26140
Min. Negotiated Rate	$332.07
Max. Negotiated Rate	$1,012.90
Rate for Payer: Aetna Commercial	$674.76
Rate for Payer: BCBS Complete	$348.67
Rate for Payer: BCBS Trust/PPO	$497.66
Rate for Payer: Cash Price	$1,157.60
Rate for Payer: Cash Price	$1,157.60
Rate for Payer: Meridian Medicaid	$348.67
Rate for Payer: Priority Health Choice Medicaid	$332.07
Rate for Payer: Priority Health Cigna Priority Health	$1,012.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$786.40
Rate for Payer: Priority Health Narrow Network	$786.40
Rate for Payer: Priority Health SBD	$786.40
Rate for Payer: UMR Bronson Commercial	$665.62

PR SYNVCT TDN SHTH RAD FLXR TDN PALM&/FNGR EA TDN

Professional

Both

$1,647.00

Service Code	HCPCS 26145
Min. Negotiated Rate	$273.13
Max. Negotiated Rate	$1,152.90
Rate for Payer: Aetna Commercial	$684.95
Rate for Payer: BCBS Complete	$353.82
Rate for Payer: BCBS Trust/PPO	$273.13
Rate for Payer: Cash Price	$1,317.60
Rate for Payer: Cash Price	$1,317.60
Rate for Payer: Meridian Medicaid	$353.82
Rate for Payer: Priority Health Choice Medicaid	$336.97
Rate for Payer: Priority Health Cigna Priority Health	$1,152.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$799.16
Rate for Payer: Priority Health Narrow Network	$799.16
Rate for Payer: Priority Health SBD	$799.16
Rate for Payer: UMR Bronson Commercial	$757.62

PR SYNVCT XTNSR TDN SHTH WRST 1 RESCJ DSTL ULNA

Professional

Both

$1,761.00

Service Code	HCPCS 25119
Min. Negotiated Rate	$39.09
Max. Negotiated Rate	$1,232.70
Rate for Payer: Aetna Commercial	$663.09
Rate for Payer: BCBS Complete	$344.64
Rate for Payer: BCBS Trust/PPO	$39.09
Rate for Payer: Cash Price	$1,408.80
Rate for Payer: Cash Price	$1,408.80
Rate for Payer: Meridian Medicaid	$344.64
Rate for Payer: Priority Health Choice Medicaid	$328.23
Rate for Payer: Priority Health Cigna Priority Health	$1,232.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$778.74
Rate for Payer: Priority Health Narrow Network	$778.74
Rate for Payer: Priority Health SBD	$778.74
Rate for Payer: UMR Bronson Commercial	$810.06

PR SYNVISC OR SYNVISC-ONE

Professional

Both

$50.00

Service Code	HCPCS J7325
Min. Negotiated Rate	$9.29
Max. Negotiated Rate	$35.00
Rate for Payer: Aetna Commercial	$9.40
Rate for Payer: BCBS Complete	$20.00
Rate for Payer: BCBS Trust/PPO	$9.29
Rate for Payer: Cash Price	$40.00
Rate for Payer: Cash Price	$40.00
Rate for Payer: Priority Health Cigna Priority Health	$35.00
Rate for Payer: UMR Bronson Commercial	$23.00

PR TANGENTIAL BIOPSY SKIN EA SEP/ADDITIONAL LESION

Professional

Both

$103.00

Service Code	HCPCS 11103
Min. Negotiated Rate	$13.85
Max. Negotiated Rate	$562.50
Rate for Payer: Aetna Commercial	$23.78
Rate for Payer: BCBS Complete	$14.54
Rate for Payer: BCBS Trust/PPO	$562.50
Rate for Payer: Cash Price	$82.40
Rate for Payer: Cash Price	$82.40
Rate for Payer: Meridian Medicaid	$14.54
Rate for Payer: Priority Health Choice Medicaid	$13.85
Rate for Payer: Priority Health Cigna Priority Health	$72.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$26.31
Rate for Payer: Priority Health Narrow Network	$26.31
Rate for Payer: Priority Health SBD	$26.31
Rate for Payer: UMR Bronson Commercial	$47.38

PR TANGENTIAL BIOPSY SKIN SINGLE LESION

Professional

Both

$190.00

Service Code	HCPCS 11102
Min. Negotiated Rate	$23.86
Max. Negotiated Rate	$285.54
Rate for Payer: Aetna Commercial	$40.50
Rate for Payer: BCBS Complete	$25.05
Rate for Payer: BCBS Trust/PPO	$285.54
Rate for Payer: Cash Price	$152.00
Rate for Payer: Cash Price	$152.00
Rate for Payer: Meridian Medicaid	$25.05
Rate for Payer: Priority Health Choice Medicaid	$23.86
Rate for Payer: Priority Health Cigna Priority Health	$133.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$46.03
Rate for Payer: Priority Health Narrow Network	$46.03
Rate for Payer: Priority Health SBD	$46.03
Rate for Payer: UMR Bronson Commercial	$87.40

PR TAP BLOCK UNILATERAL BY INJECTION(S)

Professional

Both

$112.00

Service Code	HCPCS 64486
Min. Negotiated Rate	$34.72
Max. Negotiated Rate	$92.98
Rate for Payer: Aetna Commercial	$72.82
Rate for Payer: BCBS Complete	$36.46
Rate for Payer: BCBS Trust/PPO	$92.98
Rate for Payer: Cash Price	$89.60
Rate for Payer: Cash Price	$89.60
Rate for Payer: Meridian Medicaid	$36.46
Rate for Payer: Priority Health Choice Medicaid	$34.72
Rate for Payer: Priority Health Cigna Priority Health	$78.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$92.30
Rate for Payer: Priority Health Narrow Network	$92.30
Rate for Payer: Priority Health SBD	$92.30
Rate for Payer: UMR Bronson Commercial	$51.52

PR TATTOOING INCL MICROPIGMENTATION 6.0 CM/<

Professional

Both

$317.00

Service Code	HCPCS 11920
Min. Negotiated Rate	$72.63
Max. Negotiated Rate	$630.49
Rate for Payer: Aetna Commercial	$118.80
Rate for Payer: BCBS Complete	$76.26
Rate for Payer: BCBS Trust/PPO	$630.49
Rate for Payer: Cash Price	$253.60
Rate for Payer: Cash Price	$253.60
Rate for Payer: Meridian Medicaid	$76.26
Rate for Payer: Priority Health Choice Medicaid	$72.63
Rate for Payer: Priority Health Cigna Priority Health	$221.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$133.17
Rate for Payer: Priority Health Narrow Network	$133.17
Rate for Payer: Priority Health SBD	$133.17
Rate for Payer: UMR Bronson Commercial	$145.82

PR TATTOOING INCL MICROPIGMENTATION 6.1-20.0 CM

Professional

Both

$365.00

Service Code	HCPCS 11921
Min. Negotiated Rate	$83.28
Max. Negotiated Rate	$2,064.94
Rate for Payer: Aetna Commercial	$140.70
Rate for Payer: BCBS Complete	$87.44
Rate for Payer: BCBS Trust/PPO	$2,064.94
Rate for Payer: Cash Price	$292.00
Rate for Payer: Cash Price	$292.00
Rate for Payer: Meridian Medicaid	$87.44
Rate for Payer: Priority Health Choice Medicaid	$83.28
Rate for Payer: Priority Health Cigna Priority Health	$255.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$160.31
Rate for Payer: Priority Health Narrow Network	$160.31
Rate for Payer: Priority Health SBD	$160.31
Rate for Payer: UMR Bronson Commercial	$167.90

PR TATTOOING INCL MICROPIGMENTATION EA 20.0 CM

Professional

Both

$119.00

Service Code	HCPCS 11922
Min. Negotiated Rate	$18.32
Max. Negotiated Rate	$83.30
Rate for Payer: Aetna Commercial	$31.98
Rate for Payer: BCBS Complete	$19.24
Rate for Payer: BCBS Trust/PPO	$62.82
Rate for Payer: Cash Price	$95.20
Rate for Payer: Cash Price	$95.20
Rate for Payer: Meridian Medicaid	$19.24
Rate for Payer: Priority Health Choice Medicaid	$18.32
Rate for Payer: Priority Health Cigna Priority Health	$83.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$35.76
Rate for Payer: Priority Health Narrow Network	$35.76
Rate for Payer: Priority Health SBD	$35.76
Rate for Payer: UMR Bronson Commercial	$54.74

PR TC99M DISOFENIN

Professional

Both

$250.00

Service Code	HCPCS A9510
Min. Negotiated Rate	$67.20
Max. Negotiated Rate	$1,959.99
Rate for Payer: Aetna Commercial	$67.20
Rate for Payer: BCBS Complete	$100.00
Rate for Payer: BCBS Trust/PPO	$1,959.99
Rate for Payer: Cash Price	$200.00
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

Know your out-of-pocket cost for care.

All Charges