Bronson Methodist Hospital

All Charges

Charge

Type

Setting

Price

PR UMBILECTOMY OMPHALECTOMY EXC UMBILICUS SPX

Professional

Both

$1,967.00

Service Code	HCPCS 49250
Min. Negotiated Rate	$382.55
Max. Negotiated Rate	$1,376.90
Rate for Payer: Aetna Commercial	$790.38
Rate for Payer: BCBS Complete	$401.68
Rate for Payer: BCBS Trust/PPO	$996.37
Rate for Payer: Cash Price	$1,573.60
Rate for Payer: Cash Price	$1,573.60
Rate for Payer: Meridian Medicaid	$401.68
Rate for Payer: Priority Health Choice Medicaid	$382.55
Rate for Payer: Priority Health Cigna Priority Health	$1,376.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,047.18
Rate for Payer: Priority Health Narrow Network	$1,047.18
Rate for Payer: Priority Health SBD	$1,047.18
Rate for Payer: UMR Bronson Commercial	$904.82

PR UNILATERAL BREAST AUGMENTATION GEL

Professional

Both

$2,720.00

Service Code	HCPCS 00362
Hospital Revenue Code	990
Min. Negotiated Rate	$1,088.00
Max. Negotiated Rate	$1,904.00
Rate for Payer: BCBS Complete	$1,088.00
Rate for Payer: Cash Price	$2,176.00
Rate for Payer: Priority Health Cigna Priority Health	$1,904.00
Rate for Payer: UMR Bronson Commercial	$1,251.20

PR UNILATERAL BREAST AUGMENTATION SALINE

Professional

Both

$2,120.00

Service Code	HCPCS 00363
Hospital Revenue Code	990
Min. Negotiated Rate	$848.00
Max. Negotiated Rate	$1,484.00
Rate for Payer: BCBS Complete	$848.00
Rate for Payer: Cash Price	$1,696.00
Rate for Payer: Priority Health Cigna Priority Health	$1,484.00
Rate for Payer: UMR Bronson Commercial	$975.20

PR UNLISTED DIAGNOSTIC GASTROENTEROLOGY PROCEDURE

Professional

Both

$310.00

Service Code	HCPCS 91299
Min. Negotiated Rate	$124.00
Max. Negotiated Rate	$749.66
Rate for Payer: BCBS Complete	$124.00
Rate for Payer: BCBS Trust/PPO	$749.66
Rate for Payer: Cash Price	$248.00
Rate for Payer: Cash Price	$248.00
Rate for Payer: Priority Health Cigna Priority Health	$217.00
Rate for Payer: UMR Bronson Commercial	$142.60

PR UNLISTED EVALUATION AND MANAGEMENT SERVICE

Professional

Both

$45.00

Service Code	HCPCS 99499
Min. Negotiated Rate	$18.00
Max. Negotiated Rate	$75.02
Rate for Payer: BCBS Complete	$18.00
Rate for Payer: BCBS Trust/PPO	$75.02
Rate for Payer: Cash Price	$36.00
Rate for Payer: Cash Price	$36.00
Rate for Payer: Priority Health Cigna Priority Health	$31.50
Rate for Payer: UMR Bronson Commercial	$20.70

PR UNLISTED PSYCHIATRIC SERVICE/PROCEDURE

Professional

Both

$130.00

Service Code	HCPCS 90899
Min. Negotiated Rate	$52.00
Max. Negotiated Rate	$681.51
Rate for Payer: BCBS Complete	$52.00
Rate for Payer: BCBS Trust/PPO	$681.51
Rate for Payer: Cash Price	$104.00
Rate for Payer: Cash Price	$104.00
Rate for Payer: Priority Health Cigna Priority Health	$91.00
Rate for Payer: UMR Bronson Commercial	$59.80

PR UPG PACEMAKER SYS CONVERT 1CHMBR SYS 2CHMBR SYS

Professional

Both

$974.00

Service Code	HCPCS 33214
Min. Negotiated Rate	$300.97
Max. Negotiated Rate	$1,455.47
Rate for Payer: Aetna Commercial	$643.11
Rate for Payer: BCBS Complete	$316.02
Rate for Payer: BCBS Trust/PPO	$1,455.47
Rate for Payer: Cash Price	$779.20
Rate for Payer: Cash Price	$779.20
Rate for Payer: Meridian Medicaid	$316.02
Rate for Payer: Priority Health Choice Medicaid	$300.97
Rate for Payer: Priority Health Cigna Priority Health	$681.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$754.85
Rate for Payer: Priority Health Narrow Network	$754.85
Rate for Payer: Priority Health SBD	$754.85
Rate for Payer: UMR Bronson Commercial	$448.04

PR UPPER EXT FX ORTHOSIS RAD/UL

Professional

Both

$343.00

Service Code	HCPCS L3982
Min. Negotiated Rate	$137.20
Max. Negotiated Rate	$240.10
Rate for Payer: Aetna Commercial	$215.32
Rate for Payer: BCBS Complete	$137.20
Rate for Payer: Cash Price	$274.40
Rate for Payer: Cash Price	$274.40
Rate for Payer: Priority Health Cigna Priority Health	$240.10
Rate for Payer: UMR Bronson Commercial	$157.78

PR UPPER EXT FX ORTHOSIS WRIST

Professional

Both

$302.00

Service Code	HCPCS L3984
Min. Negotiated Rate	$120.80
Max. Negotiated Rate	$211.40
Rate for Payer: Aetna Commercial	$189.68
Rate for Payer: BCBS Complete	$120.80
Rate for Payer: Cash Price	$241.60
Rate for Payer: Cash Price	$241.60
Rate for Payer: Priority Health Cigna Priority Health	$211.40
Rate for Payer: UMR Bronson Commercial	$138.92

PR UPPER GI ENDOSCOPY,STENT PLACEMENT

Professional

Both

$1,087.00

Service Code	HCPCS 43256
Min. Negotiated Rate	$434.80
Max. Negotiated Rate	$760.90
Rate for Payer: BCBS Complete	$434.80
Rate for Payer: Cash Price	$869.60
Rate for Payer: Priority Health Cigna Priority Health	$760.90
Rate for Payer: UMR Bronson Commercial	$500.02

PR UPPER GI ENDOSCOPY,TUMOR ABLATN

Professional

Both

$1,196.00

Service Code	HCPCS 43258
Min. Negotiated Rate	$478.40
Max. Negotiated Rate	$837.20
Rate for Payer: BCBS Complete	$478.40
Rate for Payer: Cash Price	$956.80
Rate for Payer: Priority Health Cigna Priority Health	$837.20
Rate for Payer: UMR Bronson Commercial	$550.16

PR UPPER LID BLEPHAROPLASTY

Professional

Both

$1,800.00

Service Code	HCPCS 00530
Hospital Revenue Code	990
Min. Negotiated Rate	$720.00
Max. Negotiated Rate	$1,260.00
Rate for Payer: BCBS Complete	$720.00
Rate for Payer: Cash Price	$1,440.00
Rate for Payer: Priority Health Cigna Priority Health	$1,260.00
Rate for Payer: UMR Bronson Commercial	$828.00

PR URETERAL ENDOSCOPY VIA URETEROSTOMY

Professional

Both

$704.00

Service Code	HCPCS 50951
Min. Negotiated Rate	$192.77
Max. Negotiated Rate	$2,683.76
Rate for Payer: Aetna Commercial	$393.03
Rate for Payer: BCBS Complete	$202.41
Rate for Payer: BCBS Trust/PPO	$2,683.76
Rate for Payer: Cash Price	$563.20
Rate for Payer: Cash Price	$563.20
Rate for Payer: Meridian Medicaid	$202.41
Rate for Payer: Priority Health Choice Medicaid	$192.77
Rate for Payer: Priority Health Cigna Priority Health	$492.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$483.08
Rate for Payer: Priority Health Narrow Network	$483.08
Rate for Payer: Priority Health SBD	$483.08
Rate for Payer: UMR Bronson Commercial	$323.84

PR URETERAL ENDOSCOPY VIA URETEROST W/RMVL FB/STONE

Professional

Both

$754.00

Service Code	HCPCS 50961
Min. Negotiated Rate	$199.16
Max. Negotiated Rate	$2,814.78
Rate for Payer: Aetna Commercial	$405.90
Rate for Payer: BCBS Complete	$209.12
Rate for Payer: BCBS Trust/PPO	$2,814.78
Rate for Payer: Cash Price	$603.20
Rate for Payer: Cash Price	$603.20
Rate for Payer: Meridian Medicaid	$209.12
Rate for Payer: Priority Health Choice Medicaid	$199.16
Rate for Payer: Priority Health Cigna Priority Health	$527.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$499.84
Rate for Payer: Priority Health Narrow Network	$499.84
Rate for Payer: Priority Health SBD	$499.84
Rate for Payer: UMR Bronson Commercial	$346.84

PR URETEROILEAL CONDUIT W/INTESTINE ANASTOMOSIS

Professional

Both

$3,389.00

Service Code	HCPCS 50820
Min. Negotiated Rate	$831.34
Max. Negotiated Rate	$3,097.95
Rate for Payer: Aetna Commercial	$1,686.79
Rate for Payer: BCBS Complete	$872.91
Rate for Payer: BCBS Trust/PPO	$3,097.95
Rate for Payer: Cash Price	$2,711.20
Rate for Payer: Cash Price	$2,711.20
Rate for Payer: Meridian Medicaid	$872.91
Rate for Payer: Priority Health Choice Medicaid	$831.34
Rate for Payer: Priority Health Cigna Priority Health	$2,372.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,088.48
Rate for Payer: Priority Health Narrow Network	$2,088.48
Rate for Payer: Priority Health SBD	$2,088.48
Rate for Payer: UMR Bronson Commercial	$1,558.94

PR URETEROLYSIS FOR OVARIAN VEIN SYNDROME

Professional

Both

$2,581.00

Service Code	HCPCS 50722
Min. Negotiated Rate	$652.42
Max. Negotiated Rate	$4,734.10
Rate for Payer: Aetna Commercial	$1,324.66
Rate for Payer: BCBS Complete	$685.04
Rate for Payer: BCBS Trust/PPO	$4,734.10
Rate for Payer: Cash Price	$2,064.80
Rate for Payer: Cash Price	$2,064.80
Rate for Payer: Meridian Medicaid	$685.04
Rate for Payer: Priority Health Choice Medicaid	$652.42
Rate for Payer: Priority Health Cigna Priority Health	$1,806.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,647.01
Rate for Payer: Priority Health Narrow Network	$1,647.01
Rate for Payer: Priority Health SBD	$1,647.01
Rate for Payer: UMR Bronson Commercial	$1,187.26

PR URETEROLYSIS W/WORPSG URETER RETROPERIT FIBROSIS

Professional

Both

$2,225.00

Service Code	HCPCS 50715
Min. Negotiated Rate	$770.21
Max. Negotiated Rate	$4,058.93
Rate for Payer: Aetna Commercial	$1,548.70
Rate for Payer: BCBS Complete	$808.72
Rate for Payer: BCBS Trust/PPO	$4,058.93
Rate for Payer: Cash Price	$1,780.00
Rate for Payer: Cash Price	$1,780.00
Rate for Payer: Meridian Medicaid	$808.72
Rate for Payer: Priority Health Choice Medicaid	$770.21
Rate for Payer: Priority Health Cigna Priority Health	$1,557.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,935.02
Rate for Payer: Priority Health Narrow Network	$1,935.02
Rate for Payer: Priority Health SBD	$1,935.02
Rate for Payer: UMR Bronson Commercial	$1,023.50

PR URETERONEOCYSTOSTOMY ANAST 1 URETER BLADDER

Professional

Both

$2,052.00

Service Code	HCPCS 50780
Min. Negotiated Rate	$706.73
Max. Negotiated Rate	$2,795.76
Rate for Payer: Aetna Commercial	$1,427.06
Rate for Payer: BCBS Complete	$742.07
Rate for Payer: BCBS Trust/PPO	$2,795.76
Rate for Payer: Cash Price	$1,641.60
Rate for Payer: Cash Price	$1,641.60
Rate for Payer: Meridian Medicaid	$742.07
Rate for Payer: Priority Health Choice Medicaid	$706.73
Rate for Payer: Priority Health Cigna Priority Health	$1,436.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,769.68
Rate for Payer: Priority Health Narrow Network	$1,769.68
Rate for Payer: Priority Health SBD	$1,769.68
Rate for Payer: UMR Bronson Commercial	$943.92

PR URETERONEOCYSTOSTOMY ANAST DUPLICATE URETER BLDR

Professional

Both

$2,192.00

Service Code	HCPCS 50782
Min. Negotiated Rate	$680.96
Max. Negotiated Rate	$2,758.25
Rate for Payer: Aetna Commercial	$1,378.95
Rate for Payer: BCBS Complete	$715.01
Rate for Payer: BCBS Trust/PPO	$2,758.25
Rate for Payer: Cash Price	$1,753.60
Rate for Payer: Cash Price	$1,753.60
Rate for Payer: Meridian Medicaid	$715.01
Rate for Payer: Priority Health Choice Medicaid	$680.96
Rate for Payer: Priority Health Cigna Priority Health	$1,534.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,708.06
Rate for Payer: Priority Health Narrow Network	$1,708.06
Rate for Payer: Priority Health SBD	$1,708.06
Rate for Payer: UMR Bronson Commercial	$1,008.32

PR URETERONEOCYSTOSTOMY W/URETERAL TAILORING

Professional

Both

$2,299.00

Service Code	HCPCS 50783
Min. Negotiated Rate	$713.76
Max. Negotiated Rate	$3,020.82
Rate for Payer: Aetna Commercial	$1,446.33
Rate for Payer: BCBS Complete	$749.45
Rate for Payer: BCBS Trust/PPO	$3,020.82
Rate for Payer: Cash Price	$1,839.20
Rate for Payer: Cash Price	$1,839.20
Rate for Payer: Meridian Medicaid	$749.45
Rate for Payer: Priority Health Choice Medicaid	$713.76
Rate for Payer: Priority Health Cigna Priority Health	$1,609.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,790.20
Rate for Payer: Priority Health Narrow Network	$1,790.20
Rate for Payer: Priority Health SBD	$1,790.20
Rate for Payer: UMR Bronson Commercial	$1,057.54

PR URETEROPYELOSTOMY ANAST URETER RENAL PELVIS

Professional

Both

$2,513.00

Service Code	HCPCS 50740
Min. Negotiated Rate	$784.48
Max. Negotiated Rate	$2,670.03
Rate for Payer: Aetna Commercial	$1,593.30
Rate for Payer: BCBS Complete	$823.70
Rate for Payer: BCBS Trust/PPO	$2,670.03
Rate for Payer: Cash Price	$2,010.40
Rate for Payer: Cash Price	$2,010.40
Rate for Payer: Meridian Medicaid	$823.70
Rate for Payer: Priority Health Choice Medicaid	$784.48
Rate for Payer: Priority Health Cigna Priority Health	$1,759.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,977.17
Rate for Payer: Priority Health Narrow Network	$1,977.17
Rate for Payer: Priority Health SBD	$1,977.17
Rate for Payer: UMR Bronson Commercial	$1,155.98

PR URETERORRHAPHY SUTURE URETER SEPARATE PROCEDURE

Professional

Both

$1,734.00

Service Code	HCPCS 50900
Min. Negotiated Rate	$535.91
Max. Negotiated Rate	$1,443.84
Rate for Payer: Aetna Commercial	$1,080.97
Rate for Payer: BCBS Complete	$562.71
Rate for Payer: BCBS Trust/PPO	$1,443.84
Rate for Payer: Cash Price	$1,387.20
Rate for Payer: Cash Price	$1,387.20
Rate for Payer: Meridian Medicaid	$562.71
Rate for Payer: Priority Health Choice Medicaid	$535.91
Rate for Payer: Priority Health Cigna Priority Health	$1,213.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,342.79
Rate for Payer: Priority Health Narrow Network	$1,342.79
Rate for Payer: Priority Health SBD	$1,342.79
Rate for Payer: UMR Bronson Commercial	$797.64

PR URETEROTOMY INSERTION INDWELLING STENT ALL TYPES

Professional

Both

$1,994.00

Service Code	HCPCS 50605
Min. Negotiated Rate	$643.69
Max. Negotiated Rate	$1,619.45
Rate for Payer: Aetna Commercial	$1,291.91
Rate for Payer: BCBS Complete	$675.87
Rate for Payer: BCBS Trust/PPO	$1,128.98
Rate for Payer: Cash Price	$1,595.20
Rate for Payer: Cash Price	$1,595.20
Rate for Payer: Meridian Medicaid	$675.87
Rate for Payer: Priority Health Choice Medicaid	$643.69
Rate for Payer: Priority Health Cigna Priority Health	$1,395.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,619.45
Rate for Payer: Priority Health Narrow Network	$1,619.45
Rate for Payer: Priority Health SBD	$1,619.45
Rate for Payer: UMR Bronson Commercial	$917.24

PR URETEROURETEROSTOMY

Professional

Both

$2,069.00

Service Code	HCPCS 50760
Min. Negotiated Rate	$718.24
Max. Negotiated Rate	$2,592.37
Rate for Payer: Aetna Commercial	$1,464.50
Rate for Payer: BCBS Complete	$754.15
Rate for Payer: BCBS Trust/PPO	$2,592.37
Rate for Payer: Cash Price	$1,655.20
Rate for Payer: Cash Price	$1,655.20
Rate for Payer: Meridian Medicaid	$754.15
Rate for Payer: Priority Health Choice Medicaid	$718.24
Rate for Payer: Priority Health Cigna Priority Health	$1,448.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,810.74
Rate for Payer: Priority Health Narrow Network	$1,810.74
Rate for Payer: Priority Health SBD	$1,810.74
Rate for Payer: UMR Bronson Commercial	$951.74

PR URETHRECTOMY TOT W/CYSTOST MALE

Professional

Both

$1,890.00

Service Code	HCPCS 53215
Min. Negotiated Rate	$397.81
Max. Negotiated Rate	$1,476.80
Rate for Payer: Aetna Commercial	$1,189.75
Rate for Payer: BCBS Complete	$617.27
Rate for Payer: BCBS Trust/PPO	$397.81
Rate for Payer: Cash Price	$1,512.00
Rate for Payer: Cash Price	$1,512.00
Rate for Payer: Meridian Medicaid	$617.27
Rate for Payer: Priority Health Choice Medicaid	$587.88
Rate for Payer: Priority Health Cigna Priority Health	$1,323.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,476.80
Rate for Payer: Priority Health Narrow Network	$1,476.80
Rate for Payer: Priority Health SBD	$1,476.80
Rate for Payer: UMR Bronson Commercial	$869.40

Know your out-of-pocket cost for care.

All Charges