Bronson Methodist Hospital

All Charges

Charge

Type

Setting

Price

PR VITAMIN B12 INJECTION

Professional

Both

$5.00

Service Code	HCPCS J3420
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$3.50
Rate for Payer: Aetna Commercial	$1.49
Rate for Payer: BCBS Complete	$2.00
Rate for Payer: BCBS Trust/PPO	$0.11
Rate for Payer: Cash Price	$4.00
Rate for Payer: Cash Price	$4.00
Rate for Payer: Priority Health Cigna Priority Health	$3.50
Rate for Payer: UMR Bronson Commercial	$2.30

PR VITAMIN K PHYTONADIONE INJ

Professional

Both

$5.00

Service Code	HCPCS J3430
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$3.50
Rate for Payer: Aetna Commercial	$2.99
Rate for Payer: BCBS Complete	$2.00
Rate for Payer: BCBS Trust/PPO	$2.62
Rate for Payer: Cash Price	$4.00
Rate for Payer: Cash Price	$4.00
Rate for Payer: Priority Health Cigna Priority Health	$3.50
Rate for Payer: UMR Bronson Commercial	$2.30

PR VLVP MITRAL VALVE W/BYPASS RAD RCNSTJ W/WO RING

Professional

Both

$5,023.80

Service Code	HCPCS 33427
Min. Negotiated Rate	$359.24
Max. Negotiated Rate	$3,796.58
Rate for Payer: Aetna Commercial	$3,275.80
Rate for Payer: BCBS Complete	$1,602.68
Rate for Payer: BCBS Trust/PPO	$359.24
Rate for Payer: Cash Price	$4,019.04
Rate for Payer: Cash Price	$4,019.04
Rate for Payer: Meridian Medicaid	$1,602.68
Rate for Payer: Priority Health Choice Medicaid	$1,526.36
Rate for Payer: Priority Health Cigna Priority Health	$3,516.66
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$3,796.58
Rate for Payer: Priority Health Narrow Network	$3,796.58
Rate for Payer: Priority Health SBD	$3,796.58
Rate for Payer: UMR Bronson Commercial	$2,310.95

PR VLVP MITRAL VALVE W/CARD BYP W/PROSTC RING

Professional

Both

$8,728.00

Service Code	HCPCS 33426
Min. Negotiated Rate	$951.47
Max. Negotiated Rate	$6,109.60
Rate for Payer: Aetna Commercial	$3,196.20
Rate for Payer: BCBS Complete	$1,567.34
Rate for Payer: BCBS Trust/PPO	$951.47
Rate for Payer: Cash Price	$6,982.40
Rate for Payer: Cash Price	$6,982.40
Rate for Payer: Meridian Medicaid	$1,567.34
Rate for Payer: Priority Health Choice Medicaid	$1,492.70
Rate for Payer: Priority Health Cigna Priority Health	$6,109.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$3,712.54
Rate for Payer: Priority Health Narrow Network	$3,712.54
Rate for Payer: Priority Health SBD	$3,712.54
Rate for Payer: UMR Bronson Commercial	$4,014.88

PR VNPNXR <3 YEARS PHY/QHP SKILL FEMRAL/JUGLAR VEIN

Professional

Both

$81.00

Service Code	HCPCS 36400
Min. Negotiated Rate	$11.72
Max. Negotiated Rate	$2,334.03
Rate for Payer: Aetna Commercial	$25.75
Rate for Payer: BCBS Complete	$12.31
Rate for Payer: BCBS Trust/PPO	$2,334.03
Rate for Payer: Cash Price	$64.80
Rate for Payer: Cash Price	$64.80
Rate for Payer: Meridian Medicaid	$12.31
Rate for Payer: Priority Health Choice Medicaid	$11.72
Rate for Payer: Priority Health Cigna Priority Health	$56.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$29.79
Rate for Payer: Priority Health Narrow Network	$29.79
Rate for Payer: Priority Health SBD	$29.79
Rate for Payer: UMR Bronson Commercial	$37.26

PR VNPNXR 3 YEARS/> PHYS/QHP SKILL

Professional

Both

$34.00

Service Code	HCPCS 36410
Min. Negotiated Rate	$12.41
Max. Negotiated Rate	$1,232.00
Rate for Payer: Aetna Commercial	$12.41
Rate for Payer: BCBS Complete	$13.60
Rate for Payer: BCBS Trust/PPO	$1,232.00
Rate for Payer: Cash Price	$27.20
Rate for Payer: Cash Price	$27.20
Rate for Payer: Priority Health Cigna Priority Health	$23.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$14.36
Rate for Payer: Priority Health Narrow Network	$14.36
Rate for Payer: Priority Health SBD	$14.36
Rate for Payer: UMR Bronson Commercial	$15.64

PR VOID PRESSURE STUDIES INTRAABDOMINAL

Professional

Both

$508.00

Service Code	HCPCS 51797
Min. Negotiated Rate	$63.23
Max. Negotiated Rate	$3,594.55
Rate for Payer: Aetna Commercial	$231.52
Rate for Payer: BCBS Complete	$203.20
Rate for Payer: BCBS Trust/PPO	$3,594.55
Rate for Payer: Cash Price	$406.40
Rate for Payer: Cash Price	$406.40
Rate for Payer: Priority Health Cigna Priority Health	$355.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$63.23
Rate for Payer: Priority Health Narrow Network	$63.23
Rate for Payer: Priority Health SBD	$312.33
Rate for Payer: UMR Bronson Commercial	$233.68

PR VSTBLR FUNCJ NYSTAG FOVL&PERPH STIMJ OSCIL TRK

Professional

Both

$137.00

Service Code	HCPCS 92540
Min. Negotiated Rate	$42.66
Max. Negotiated Rate	$1,769.28
Rate for Payer: Aetna Commercial	$119.63
Rate for Payer: BCBS Complete	$54.80
Rate for Payer: BCBS Trust/PPO	$1,769.28
Rate for Payer: Cash Price	$109.60
Rate for Payer: Cash Price	$109.60
Rate for Payer: Priority Health Cigna Priority Health	$95.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$42.66
Rate for Payer: Priority Health Narrow Network	$42.66
Rate for Payer: Priority Health SBD	$145.52
Rate for Payer: UMR Bronson Commercial	$63.02

PR VULVECTOMY RADICAL PARTIAL

Professional

Both

$1,591.00

Service Code	HCPCS 56630
Min. Negotiated Rate	$619.19
Max. Negotiated Rate	$1,855.92
Rate for Payer: Aetna Commercial	$1,132.58
Rate for Payer: BCBS Complete	$650.15
Rate for Payer: BCBS Trust/PPO	$1,855.92
Rate for Payer: Cash Price	$1,272.80
Rate for Payer: Cash Price	$1,272.80
Rate for Payer: Meridian Medicaid	$650.15
Rate for Payer: Priority Health Choice Medicaid	$619.19
Rate for Payer: Priority Health Cigna Priority Health	$1,113.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,364.41
Rate for Payer: Priority Health Narrow Network	$1,364.41
Rate for Payer: Priority Health SBD	$1,364.41
Rate for Payer: UMR Bronson Commercial	$731.86

PR VULVECTOMY SIMPLE PARTIAL

Professional

Both

$1,540.00

Service Code	HCPCS 56620
Min. Negotiated Rate	$379.35
Max. Negotiated Rate	$1,725.43
Rate for Payer: Aetna Commercial	$677.28
Rate for Payer: BCBS Complete	$398.32
Rate for Payer: BCBS Trust/PPO	$1,725.43
Rate for Payer: Cash Price	$1,232.00
Rate for Payer: Cash Price	$1,232.00
Rate for Payer: Meridian Medicaid	$398.32
Rate for Payer: Priority Health Choice Medicaid	$379.35
Rate for Payer: Priority Health Cigna Priority Health	$1,078.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$835.59
Rate for Payer: Priority Health Narrow Network	$835.59
Rate for Payer: Priority Health SBD	$835.59
Rate for Payer: UMR Bronson Commercial	$708.40

PR WEDGE EXCISION SKIN NAIL FOLD

Professional

Both

$267.00

Service Code	HCPCS 11765
Min. Negotiated Rate	$59.64
Max. Negotiated Rate	$267.10
Rate for Payer: Aetna Commercial	$94.01
Rate for Payer: BCBS Complete	$62.62
Rate for Payer: BCBS Trust/PPO	$267.10
Rate for Payer: Cash Price	$213.60
Rate for Payer: Cash Price	$213.60
Rate for Payer: Meridian Medicaid	$62.62
Rate for Payer: Priority Health Choice Medicaid	$59.64
Rate for Payer: Priority Health Cigna Priority Health	$186.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$112.62
Rate for Payer: Priority Health Narrow Network	$112.62
Rate for Payer: Priority Health SBD	$112.62
Rate for Payer: UMR Bronson Commercial	$122.82

PR WEDGE RESCJ/BISCTJ OVARY UNI/BI

Professional

Both

$1,891.00

Service Code	HCPCS 58920
Min. Negotiated Rate	$165.36
Max. Negotiated Rate	$1,323.70
Rate for Payer: Aetna Commercial	$854.80
Rate for Payer: BCBS Complete	$482.19
Rate for Payer: BCBS Trust/PPO	$165.36
Rate for Payer: Cash Price	$1,512.80
Rate for Payer: Cash Price	$1,512.80
Rate for Payer: Meridian Medicaid	$482.19
Rate for Payer: Priority Health Choice Medicaid	$459.23
Rate for Payer: Priority Health Cigna Priority Health	$1,323.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,017.39
Rate for Payer: Priority Health Narrow Network	$1,017.39
Rate for Payer: Priority Health SBD	$1,017.39
Rate for Payer: UMR Bronson Commercial	$869.86

PR WEDGING CAST EXCEPT CLUBFOOT CASTS

Professional

Both

$112.00

Service Code	HCPCS 29740
Min. Negotiated Rate	$43.88
Max. Negotiated Rate	$1,753.43
Rate for Payer: Aetna Commercial	$92.51
Rate for Payer: BCBS Complete	$46.07
Rate for Payer: BCBS Trust/PPO	$1,753.43
Rate for Payer: Cash Price	$89.60
Rate for Payer: Cash Price	$89.60
Rate for Payer: Meridian Medicaid	$46.07
Rate for Payer: Priority Health Choice Medicaid	$43.88
Rate for Payer: Priority Health Cigna Priority Health	$78.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$104.69
Rate for Payer: Priority Health Narrow Network	$104.69
Rate for Payer: Priority Health SBD	$104.69
Rate for Payer: UMR Bronson Commercial	$51.52

PR WESTONE MUSICIAN EAR PLUGS

Professional

Both

$180.00

Service Code	HCPCS 00591
Hospital Revenue Code	990
Min. Negotiated Rate	$72.00
Max. Negotiated Rate	$126.00
Rate for Payer: BCBS Complete	$72.00
Rate for Payer: Cash Price	$144.00
Rate for Payer: Priority Health Cigna Priority Health	$126.00
Rate for Payer: UMR Bronson Commercial	$82.80

PR WET MOUNTS/ W PREPARATIONS

Professional

Both

$12.00

Service Code	HCPCS Q0111
Min. Negotiated Rate	$4.80
Max. Negotiated Rate	$703.47
Rate for Payer: Aetna Commercial	$14.39
Rate for Payer: BCBS Complete	$4.80
Rate for Payer: BCBS Trust/PPO	$703.47
Rate for Payer: Cash Price	$9.60
Rate for Payer: Cash Price	$9.60
Rate for Payer: Priority Health Cigna Priority Health	$8.40
Rate for Payer: UMR Bronson Commercial	$5.52

PR WHFO, RIGID W/O JOINTS

Professional

Both

$326.00

Service Code	HCPCS L3808
Min. Negotiated Rate	$130.40
Max. Negotiated Rate	$228.20
Rate for Payer: Aetna Commercial	$195.26
Rate for Payer: BCBS Complete	$130.40
Rate for Payer: Cash Price	$260.80
Rate for Payer: Cash Price	$260.80
Rate for Payer: Priority Health Cigna Priority Health	$228.20
Rate for Payer: UMR Bronson Commercial	$149.96

PR WHFO W/O JOINTS PRE CST

Professional

Both

$229.00

Service Code	HCPCS L3807
Min. Negotiated Rate	$91.60
Max. Negotiated Rate	$160.30
Rate for Payer: Aetna Commercial	$137.06
Rate for Payer: BCBS Complete	$91.60
Rate for Payer: Cash Price	$183.20
Rate for Payer: Cash Price	$183.20
Rate for Payer: Priority Health Cigna Priority Health	$160.30
Rate for Payer: UMR Bronson Commercial	$105.34

PR WHO COCK-UP NONMOLDE PRE OTS

Professional

Both

$68.00

Service Code	HCPCS L3908
Min. Negotiated Rate	$27.20
Max. Negotiated Rate	$47.60
Rate for Payer: Aetna Commercial	$40.19
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 WHO W/NONTORSION JNT(S) CF

Professional

Both

$908.00

Service Code	HCPCS L3905
Min. Negotiated Rate	$363.20
Max. Negotiated Rate	$635.60
Rate for Payer: Aetna Commercial	$543.58
Rate for Payer: BCBS Complete	$363.20
Rate for Payer: Cash Price	$726.40
Rate for Payer: Cash Price	$726.40
Rate for Payer: Priority Health Cigna Priority Health	$635.60
Rate for Payer: UMR Bronson Commercial	$417.68

PR WHO W/O JOINTS CF

Professional

Both

$464.00

Service Code	HCPCS L3906
Min. Negotiated Rate	$185.60
Max. Negotiated Rate	$324.80
Rate for Payer: Aetna Commercial	$277.78
Rate for Payer: BCBS Complete	$185.60
Rate for Payer: Cash Price	$371.20
Rate for Payer: Cash Price	$371.20
Rate for Payer: Priority Health Cigna Priority Health	$324.80
Rate for Payer: UMR Bronson Commercial	$213.44

PR WINDOWING CAST

Professional

Both

$112.00

Service Code	HCPCS 29730
Min. Negotiated Rate	$28.54
Max. Negotiated Rate	$1,134.26
Rate for Payer: Aetna Commercial	$58.92
Rate for Payer: BCBS Complete	$29.97
Rate for Payer: BCBS Trust/PPO	$1,134.26
Rate for Payer: Cash Price	$89.60
Rate for Payer: Cash Price	$89.60
Rate for Payer: Meridian Medicaid	$29.97
Rate for Payer: Priority Health Choice Medicaid	$28.54
Rate for Payer: Priority Health Cigna Priority Health	$78.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$67.40
Rate for Payer: Priority Health Narrow Network	$67.40
Rate for Payer: Priority Health SBD	$67.40
Rate for Payer: UMR Bronson Commercial	$51.52

PR WORK HARDENING/CONDITIONING 1ST 2 HR

Professional

Both

$194.00

Service Code	HCPCS 97545
Min. Negotiated Rate	$75.00
Max. Negotiated Rate	$135.80
Rate for Payer: Aetna Commercial	$119.94
Rate for Payer: BCBS Complete	$77.60
Rate for Payer: BCBS Trust/PPO	$116.23
Rate for Payer: Cash Price	$155.20
Rate for Payer: Cash Price	$155.20
Rate for Payer: Priority Health Cigna Priority Health	$135.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$75.00
Rate for Payer: Priority Health Narrow Network	$75.00
Rate for Payer: Priority Health SBD	$75.00
Rate for Payer: UMR Bronson Commercial	$89.24

PR WORK HARDENING/CONDITIONING EACH HOUR

Professional

Both

$97.00

Service Code	HCPCS 97546
Min. Negotiated Rate	$38.80
Max. Negotiated Rate	$328.07
Rate for Payer: Aetna Commercial	$47.77
Rate for Payer: BCBS Complete	$38.80
Rate for Payer: BCBS Trust/PPO	$328.07
Rate for Payer: Cash Price	$77.60
Rate for Payer: Cash Price	$77.60
Rate for Payer: Priority Health Cigna Priority Health	$67.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$75.00
Rate for Payer: Priority Health Narrow Network	$75.00
Rate for Payer: Priority Health SBD	$75.00
Rate for Payer: UMR Bronson Commercial	$44.62

PR WORK RELATED/MED DBLT XM TREATING PHYS

Professional

Both

$110.00

Service Code	HCPCS 99455
Min. Negotiated Rate	$44.00
Max. Negotiated Rate	$165.89
Rate for Payer: Aetna Commercial	$84.95
Rate for Payer: BCBS Complete	$44.00
Rate for Payer: BCBS Trust/PPO	$165.89
Rate for Payer: Cash Price	$88.00
Rate for Payer: Cash Price	$88.00
Rate for Payer: Priority Health Cigna Priority Health	$77.00
Rate for Payer: UMR Bronson Commercial	$50.60

PR WOUND CLOSURE BY ADHESIVE

Professional

Both

$198.00

Service Code	HCPCS G0168
Min. Negotiated Rate	$9.37
Max. Negotiated Rate	$138.60
Rate for Payer: Aetna Commercial	$15.22
Rate for Payer: BCBS Complete	$9.84
Rate for Payer: BCBS Trust/PPO	$63.68
Rate for Payer: Cash Price	$158.40
Rate for Payer: Cash Price	$158.40
Rate for Payer: Meridian Medicaid	$9.84
Rate for Payer: Priority Health Choice Medicaid	$9.37
Rate for Payer: Priority Health Cigna Priority Health	$138.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$18.09
Rate for Payer: Priority Health Narrow Network	$18.09
Rate for Payer: Priority Health SBD	$18.09
Rate for Payer: UMR Bronson Commercial	$91.08

Know your out-of-pocket cost for care.

All Charges