Bronson Methodist Hospital

All Charges

Charge

Type

Setting

Price

PR TC99M MEBROFENIN

Professional

Both

$238.00

Service Code	HCPCS A9537
Min. Negotiated Rate	$53.10
Max. Negotiated Rate	$2,874.48
Rate for Payer: Aetna Commercial	$53.10
Rate for Payer: BCBS Complete	$95.20
Rate for Payer: BCBS Trust/PPO	$2,874.48
Rate for Payer: Cash Price	$190.40
Rate for Payer: Cash Price	$190.40
Rate for Payer: Priority Health Cigna Priority Health	$166.60
Rate for Payer: UMR Bronson Commercial	$109.48

PR TC99M MEDRONATE

Professional

Both

$90.00

Service Code	HCPCS A9503
Min. Negotiated Rate	$12.48
Max. Negotiated Rate	$1,603.92
Rate for Payer: Aetna Commercial	$12.48
Rate for Payer: BCBS Complete	$36.00
Rate for Payer: BCBS Trust/PPO	$1,603.92
Rate for Payer: Cash Price	$72.00
Rate for Payer: Cash Price	$72.00
Rate for Payer: Priority Health Cigna Priority Health	$63.00
Rate for Payer: UMR Bronson Commercial	$41.40

PR TC99M PERTECHNETATE

Professional

Both

$20.00

Service Code	HCPCS A9512
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$1,517.81
Rate for Payer: Aetna Commercial	$1.50
Rate for Payer: BCBS Complete	$8.00
Rate for Payer: BCBS Trust/PPO	$1,517.81
Rate for Payer: Cash Price	$16.00
Rate for Payer: Cash Price	$16.00
Rate for Payer: Priority Health Cigna Priority Health	$14.00
Rate for Payer: UMR Bronson Commercial	$9.20

PR TC99M SESTAMIBI

Professional

Both

$314.00

Service Code	HCPCS A9500
Min. Negotiated Rate	$102.48
Max. Negotiated Rate	$1,830.03
Rate for Payer: Aetna Commercial	$102.48
Rate for Payer: BCBS Complete	$125.60
Rate for Payer: BCBS Trust/PPO	$1,830.03
Rate for Payer: Cash Price	$251.20
Rate for Payer: Cash Price	$251.20
Rate for Payer: Priority Health Cigna Priority Health	$219.80
Rate for Payer: UMR Bronson Commercial	$144.44

PR TCATH STENT PLACEMT ANTEGRADE CAROTID/INNOMINATE

Professional

Both

$1,778.00

Service Code	HCPCS 37218
Min. Negotiated Rate	$517.59
Max. Negotiated Rate	$1,283.62
Rate for Payer: Aetna Commercial	$1,098.34
Rate for Payer: BCBS Complete	$543.47
Rate for Payer: BCBS Trust/PPO	$1,155.92
Rate for Payer: Cash Price	$1,422.40
Rate for Payer: Cash Price	$1,422.40
Rate for Payer: Meridian Medicaid	$543.47
Rate for Payer: Priority Health Choice Medicaid	$517.59
Rate for Payer: Priority Health Cigna Priority Health	$1,244.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,283.62
Rate for Payer: Priority Health Narrow Network	$1,283.62
Rate for Payer: Priority Health SBD	$1,283.62
Rate for Payer: UMR Bronson Commercial	$817.88

PR TCATH STENT PLACEMT RETROGRAD CAROTID/INNOMINATE

Professional

Both

$1,721.00

Service Code	HCPCS 37217
Min. Negotiated Rate	$672.65
Max. Negotiated Rate	$1,682.04
Rate for Payer: Aetna Commercial	$1,445.26
Rate for Payer: BCBS Complete	$706.28
Rate for Payer: BCBS Trust/PPO	$721.66
Rate for Payer: Cash Price	$1,376.80
Rate for Payer: Cash Price	$1,376.80
Rate for Payer: Meridian Medicaid	$706.28
Rate for Payer: Priority Health Choice Medicaid	$672.65
Rate for Payer: Priority Health Cigna Priority Health	$1,204.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,682.04
Rate for Payer: Priority Health Narrow Network	$1,682.04
Rate for Payer: Priority Health SBD	$1,682.04
Rate for Payer: UMR Bronson Commercial	$791.66

PR TCAT IMPL WRLS P-ART PRS SNR L-T HEMODYN MNTR

Professional

Both

$674.00

Service Code	HCPCS 33289
Min. Negotiated Rate	$208.53
Max. Negotiated Rate	$1,657.81
Rate for Payer: Aetna Commercial	$447.42
Rate for Payer: BCBS Complete	$218.96
Rate for Payer: BCBS Trust/PPO	$1,657.81
Rate for Payer: Cash Price	$539.20
Rate for Payer: Cash Price	$539.20
Rate for Payer: Meridian Medicaid	$218.96
Rate for Payer: Priority Health Choice Medicaid	$208.53
Rate for Payer: Priority Health Cigna Priority Health	$471.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$519.19
Rate for Payer: Priority Health Narrow Network	$519.19
Rate for Payer: Priority Health SBD	$519.19
Rate for Payer: UMR Bronson Commercial	$310.04

PR TCAT INSJ/RPL PERM LEADLESS PACEMAKER RV W/IMG

Professional

Both

$1,000.00

Service Code	HCPCS 33274
Min. Negotiated Rate	$299.90
Max. Negotiated Rate	$1,157.51
Rate for Payer: Aetna Commercial	$648.93
Rate for Payer: BCBS Complete	$314.90
Rate for Payer: BCBS Trust/PPO	$1,157.51
Rate for Payer: Cash Price	$800.00
Rate for Payer: Cash Price	$800.00
Rate for Payer: Meridian Medicaid	$314.90
Rate for Payer: Priority Health Choice Medicaid	$299.90
Rate for Payer: Priority Health Cigna Priority Health	$700.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$754.32
Rate for Payer: Priority Health Narrow Network	$754.32
Rate for Payer: Priority Health SBD	$754.32
Rate for Payer: UMR Bronson Commercial	$460.00

PR TCAT IV STENT CRV CRTD ART EMBOLIC PROTECJ

Professional

Both

$2,068.90

Service Code	HCPCS 37215
Min. Negotiated Rate	$618.55
Max. Negotiated Rate	$1,543.21
Rate for Payer: Aetna Commercial	$1,335.45
Rate for Payer: BCBS Complete	$649.48
Rate for Payer: BCBS Trust/PPO	$967.85
Rate for Payer: Cash Price	$1,655.12
Rate for Payer: Cash Price	$1,655.12
Rate for Payer: Meridian Medicaid	$649.48
Rate for Payer: Priority Health Choice Medicaid	$618.55
Rate for Payer: Priority Health Cigna Priority Health	$1,448.23
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,543.21
Rate for Payer: Priority Health Narrow Network	$1,543.21
Rate for Payer: Priority Health SBD	$1,543.21
Rate for Payer: UMR Bronson Commercial	$951.69

PR TCAT IV STENT CRV CRTD ART W/O EMBOLIC PROTECJ

Professional

Both

$4,102.00

Service Code	HCPCS 37216
Min. Negotiated Rate	$471.24
Max. Negotiated Rate	$2,871.40
Rate for Payer: Aetna Commercial	$1,302.62
Rate for Payer: BCBS Complete	$1,640.80
Rate for Payer: BCBS Trust/PPO	$471.24
Rate for Payer: Cash Price	$3,281.60
Rate for Payer: Cash Price	$3,281.60
Rate for Payer: Priority Health Cigna Priority Health	$2,871.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,542.68
Rate for Payer: Priority Health Narrow Network	$1,542.68
Rate for Payer: Priority Health SBD	$1,542.68
Rate for Payer: UMR Bronson Commercial	$1,886.92

PR TCAT MITRAL VALVE REPAIR INITIAL PROSTHESIS

Professional

Both

$3,685.00

Service Code	HCPCS 33418
Min. Negotiated Rate	$308.00
Max. Negotiated Rate	$2,794.37
Rate for Payer: Aetna Commercial	$2,411.52
Rate for Payer: BCBS Complete	$1,181.76
Rate for Payer: BCBS Trust/PPO	$308.00
Rate for Payer: Cash Price	$2,948.00
Rate for Payer: Cash Price	$2,948.00
Rate for Payer: Meridian Medicaid	$1,181.76
Rate for Payer: Priority Health Choice Medicaid	$1,125.49
Rate for Payer: Priority Health Cigna Priority Health	$2,579.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,794.37
Rate for Payer: Priority Health Narrow Network	$2,794.37
Rate for Payer: Priority Health SBD	$2,794.37
Rate for Payer: UMR Bronson Commercial	$1,695.10

PR TCAT PERMANENT OCCLUSION/EMBOLIZATION PRQ CNS

Professional

Both

$4,533.00

Service Code	HCPCS 61624
Min. Negotiated Rate	$113.06
Max. Negotiated Rate	$3,173.10
Rate for Payer: Aetna Commercial	$1,488.12
Rate for Payer: BCBS Complete	$777.63
Rate for Payer: BCBS Trust/PPO	$113.06
Rate for Payer: Cash Price	$3,626.40
Rate for Payer: Cash Price	$3,626.40
Rate for Payer: Meridian Medicaid	$777.63
Rate for Payer: Priority Health Choice Medicaid	$740.60
Rate for Payer: Priority Health Cigna Priority Health	$3,173.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,956.30
Rate for Payer: Priority Health Narrow Network	$1,956.30
Rate for Payer: Priority Health SBD	$1,956.30
Rate for Payer: UMR Bronson Commercial	$2,085.18

PR TCAT PERMANT OCCLUSION/EMBOLIZATION PRQ NON-CNS

Professional

Both

$1,812.30

Service Code	HCPCS 61626
Min. Negotiated Rate	$73.96
Max. Negotiated Rate	$1,507.86
Rate for Payer: Aetna Commercial	$1,145.58
Rate for Payer: BCBS Complete	$602.74
Rate for Payer: BCBS Trust/PPO	$73.96
Rate for Payer: Cash Price	$1,449.84
Rate for Payer: Cash Price	$1,449.84
Rate for Payer: Meridian Medicaid	$602.74
Rate for Payer: Priority Health Choice Medicaid	$574.04
Rate for Payer: Priority Health Cigna Priority Health	$1,268.61
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,507.86
Rate for Payer: Priority Health Narrow Network	$1,507.86
Rate for Payer: Priority Health SBD	$1,507.86
Rate for Payer: UMR Bronson Commercial	$833.66

PR TCAT PLMT IV STENT ICRA W/BALO ANGIOP IF PFRMD

Professional

Both

$6,660.00

Service Code	HCPCS 61635
Min. Negotiated Rate	$63.40
Max. Negotiated Rate	$4,662.00
Rate for Payer: Aetna Commercial	$1,871.57
Rate for Payer: BCBS Complete	$2,664.00
Rate for Payer: BCBS Trust/PPO	$63.40
Rate for Payer: Cash Price	$5,328.00
Rate for Payer: Cash Price	$5,328.00
Rate for Payer: Priority Health Cigna Priority Health	$4,662.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,497.05
Rate for Payer: Priority Health Narrow Network	$2,497.05
Rate for Payer: Priority Health SBD	$2,497.05
Rate for Payer: UMR Bronson Commercial	$3,063.60

PR TCAT PLMT XTRC VRT CRTD STENT RS&I PRQ 1ST VSL

Professional

Both

$9,679.00

Service Code	HCPCS 0075T
Min. Negotiated Rate	$28.95
Max. Negotiated Rate	$6,775.30
Rate for Payer: Aetna Commercial	$1,381.29
Rate for Payer: BCBS Complete	$3,871.60
Rate for Payer: BCBS Trust/PPO	$28.95
Rate for Payer: Cash Price	$7,743.20
Rate for Payer: Cash Price	$7,743.20
Rate for Payer: Priority Health Cigna Priority Health	$6,775.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,200.00
Rate for Payer: Priority Health Narrow Network	$1,200.00
Rate for Payer: Priority Health SBD	$5,900.00
Rate for Payer: UMR Bronson Commercial	$4,452.34

PR TDAP VACCINE 7 YRS/> IM

Professional

Both

$55.00

Service Code	HCPCS 90715
Min. Negotiated Rate	$22.00
Max. Negotiated Rate	$40.48
Rate for Payer: Aetna Commercial	$38.31
Rate for Payer: BCBS Complete	$22.00
Rate for Payer: BCBS Trust/PPO	$40.48
Rate for Payer: Cash Price	$44.00
Rate for Payer: Cash Price	$44.00
Rate for Payer: Priority Health Cigna Priority Health	$38.50
Rate for Payer: UMR Bronson Commercial	$25.30

PR TDN TRNSPLJ/TR FLXR/XTNSR F/ARM&/WRST 1 EA TDN

Professional

Both

$2,581.00

Service Code	HCPCS 25310
Min. Negotiated Rate	$404.49
Max. Negotiated Rate	$1,806.70
Rate for Payer: Aetna Commercial	$826.01
Rate for Payer: BCBS Complete	$424.71
Rate for Payer: BCBS Trust/PPO	$791.39
Rate for Payer: Cash Price	$2,064.80
Rate for Payer: Cash Price	$2,064.80
Rate for Payer: Meridian Medicaid	$424.71
Rate for Payer: Priority Health Choice Medicaid	$404.49
Rate for Payer: Priority Health Cigna Priority Health	$1,806.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$960.54
Rate for Payer: Priority Health Narrow Network	$960.54
Rate for Payer: Priority Health SBD	$960.54
Rate for Payer: UMR Bronson Commercial	$1,187.26

PR TDN TRNSPLJ/TR FLXR/XTNSR F/ARM&/WRST 1/TDN GR

Professional

Both

$1,552.00

Service Code	HCPCS 25312
Min. Negotiated Rate	$226.11
Max. Negotiated Rate	$1,106.59
Rate for Payer: Aetna Commercial	$951.85
Rate for Payer: BCBS Complete	$488.45
Rate for Payer: BCBS Trust/PPO	$226.11
Rate for Payer: Cash Price	$1,241.60
Rate for Payer: Cash Price	$1,241.60
Rate for Payer: Meridian Medicaid	$488.45
Rate for Payer: Priority Health Choice Medicaid	$465.19
Rate for Payer: Priority Health Cigna Priority Health	$1,086.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,106.59
Rate for Payer: Priority Health Narrow Network	$1,106.59
Rate for Payer: Priority Health SBD	$1,106.59
Rate for Payer: UMR Bronson Commercial	$713.92

PR TD VACCINE PRSRV FREE 7 YRS OR OLDER FOR IM USE

Professional

Both

$38.00

Service Code	HCPCS 90714
Min. Negotiated Rate	$15.20
Max. Negotiated Rate	$35.19
Rate for Payer: Aetna Commercial	$30.34
Rate for Payer: BCBS Complete	$15.20
Rate for Payer: BCBS Trust/PPO	$35.19
Rate for Payer: Cash Price	$30.40
Rate for Payer: Cash Price	$30.40
Rate for Payer: Priority Health Cigna Priority Health	$26.60
Rate for Payer: UMR Bronson Commercial	$17.48

PR TEAEC W/GRAFT EA ADDL TIBIAL/PERONEAL ART

Professional

Both

$924.00

Service Code	HCPCS 35306
Min. Negotiated Rate	$276.26
Max. Negotiated Rate	$991.62
Rate for Payer: Aetna Commercial	$600.76
Rate for Payer: BCBS Complete	$290.07
Rate for Payer: BCBS Trust/PPO	$991.62
Rate for Payer: Cash Price	$739.20
Rate for Payer: Cash Price	$739.20
Rate for Payer: Meridian Medicaid	$290.07
Rate for Payer: Priority Health Choice Medicaid	$276.26
Rate for Payer: Priority Health Cigna Priority Health	$646.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$689.95
Rate for Payer: Priority Health Narrow Network	$689.95
Rate for Payer: Priority Health SBD	$689.95
Rate for Payer: UMR Bronson Commercial	$425.04

PR TEAEC W/GRAFT POPLITEAL ARTERY

Professional

Both

$2,340.00

Service Code	HCPCS 35303
Min. Negotiated Rate	$764.24
Max. Negotiated Rate	$1,921.44
Rate for Payer: Aetna Commercial	$1,662.68
Rate for Payer: BCBS Complete	$802.45
Rate for Payer: BCBS Trust/PPO	$903.39
Rate for Payer: Cash Price	$1,872.00
Rate for Payer: Cash Price	$1,872.00
Rate for Payer: Meridian Medicaid	$802.45
Rate for Payer: Priority Health Choice Medicaid	$764.24
Rate for Payer: Priority Health Cigna Priority Health	$1,638.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,921.44
Rate for Payer: Priority Health Narrow Network	$1,921.44
Rate for Payer: Priority Health SBD	$1,921.44
Rate for Payer: UMR Bronson Commercial	$1,076.40

PR TEAEC W/GRAFT SUPERFICIAL FEMORAL ARTERY

Professional

Both

$2,149.00

Service Code	HCPCS 35302
Min. Negotiated Rate	$655.62
Max. Negotiated Rate	$1,738.43
Rate for Payer: Aetna Commercial	$1,506.99
Rate for Payer: BCBS Complete	$732.01
Rate for Payer: BCBS Trust/PPO	$655.62
Rate for Payer: Cash Price	$1,719.20
Rate for Payer: Cash Price	$1,719.20
Rate for Payer: Meridian Medicaid	$732.01
Rate for Payer: Priority Health Choice Medicaid	$697.15
Rate for Payer: Priority Health Cigna Priority Health	$1,504.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,738.43
Rate for Payer: Priority Health Narrow Network	$1,738.43
Rate for Payer: Priority Health SBD	$1,738.43
Rate for Payer: UMR Bronson Commercial	$988.54

PR TEAEC W/GRAFT TIBIAL/PERONEAL ART 1ST VESSEL

Professional

Both

$2,364.00

Service Code	HCPCS 35305
Min. Negotiated Rate	$501.36
Max. Negotiated Rate	$1,899.08
Rate for Payer: Aetna Commercial	$1,655.42
Rate for Payer: BCBS Complete	$803.58
Rate for Payer: BCBS Trust/PPO	$501.36
Rate for Payer: Cash Price	$1,891.20
Rate for Payer: Cash Price	$1,891.20
Rate for Payer: Meridian Medicaid	$803.58
Rate for Payer: Priority Health Choice Medicaid	$765.31
Rate for Payer: Priority Health Cigna Priority Health	$1,654.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,899.08
Rate for Payer: Priority Health Narrow Network	$1,899.08
Rate for Payer: Priority Health SBD	$1,899.08
Rate for Payer: UMR Bronson Commercial	$1,087.44

PR TEAEC W/GRAFT TIBIOPERONEAL TRUNK ARTERY

Professional

Both

$2,460.00

Service Code	HCPCS 35304
Min. Negotiated Rate	$795.56
Max. Negotiated Rate	$1,973.57
Rate for Payer: Aetna Commercial	$1,711.17
Rate for Payer: BCBS Complete	$835.34
Rate for Payer: BCBS Trust/PPO	$836.83
Rate for Payer: Cash Price	$1,968.00
Rate for Payer: Cash Price	$1,968.00
Rate for Payer: Meridian Medicaid	$835.34
Rate for Payer: Priority Health Choice Medicaid	$795.56
Rate for Payer: Priority Health Cigna Priority Health	$1,722.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,973.57
Rate for Payer: Priority Health Narrow Network	$1,973.57
Rate for Payer: Priority Health SBD	$1,973.57
Rate for Payer: UMR Bronson Commercial	$1,131.60

PR TEAEC W/PATCH GRF CAROTID VERTB SUBCLAV NECK INC

Professional

Both

$3,625.00

Service Code	HCPCS 35301
Min. Negotiated Rate	$276.83
Max. Negotiated Rate	$2,537.50
Rate for Payer: Aetna Commercial	$1,520.42
Rate for Payer: BCBS Complete	$740.28
Rate for Payer: BCBS Trust/PPO	$276.83
Rate for Payer: Cash Price	$2,900.00
Rate for Payer: Cash Price	$2,900.00
Rate for Payer: Meridian Medicaid	$740.28
Rate for Payer: Priority Health Choice Medicaid	$705.03
Rate for Payer: Priority Health Cigna Priority Health	$2,537.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,756.00
Rate for Payer: Priority Health Narrow Network	$1,756.00
Rate for Payer: Priority Health SBD	$1,756.00
Rate for Payer: UMR Bronson Commercial	$1,667.50

Know your out-of-pocket cost for care.

All Charges