Bronson Methodist Hospital

All Charges

Charge

Type

Setting

Price

PR PENTAMIDINE AERSL INHALATION PNEUMOCYSTIS/PROPH

Professional

Both

$190.00

Service Code	HCPCS 94642
Min. Negotiated Rate	$76.00
Max. Negotiated Rate	$123.50
Rate for Payer: Aetna Medicare	$95.00
Rate for Payer: BCBS Complete	$76.00
Rate for Payer: Cash Price	$152.00
Rate for Payer: Priority Health Cigna Priority Health	$123.50
Rate for Payer: UMR Bronson Commercial	$87.40

PR PERCUTANEOUS TRANSLUMINAL CORONARY LITHOTRIPSY

Professional

Both

$233.00

Service Code	HCPCS 92972
Min. Negotiated Rate	$93.20
Max. Negotiated Rate	$198.62
Rate for Payer: Aetna Commercial	$184.83
Rate for Payer: Aetna Medicare	$143.45
Rate for Payer: Aetna New Business (MI Preferred)	$184.83
Rate for Payer: Aetna New Business (MI Preferred)	$198.62
Rate for Payer: BCBS Complete	$93.20
Rate for Payer: BCBS MAPPO	$137.93
Rate for Payer: BCN Medicare Advantage	$137.93
Rate for Payer: Cash Price	$186.40
Rate for Payer: Cash Price	$186.40
Rate for Payer: Cofinity Commercial	$184.83
Rate for Payer: Cofinity Commercial	$198.62
Rate for Payer: Health Alliance Plan Medicare Advantage	$137.93
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$144.83
Rate for Payer: Nomi Health Commercial	$165.52
Rate for Payer: PACE SWMI	$137.93
Rate for Payer: PHP Commercial	$193.10
Rate for Payer: PHP Medicare Advantage	$137.93
Rate for Payer: Priority Health Cigna Priority Health	$151.45
Rate for Payer: Priority Health Medicare	$137.93
Rate for Payer: UHC Dual Complete DSNP	$137.93
Rate for Payer: UHC Medicare Advantage	$137.93
Rate for Payer: UMR Bronson Commercial	$107.18

PR PERCUTANEOUS TX MALAR AREA FRACTURE

Professional

Both

$916.00

Service Code	HCPCS 21355
Min. Negotiated Rate	$312.53
Max. Negotiated Rate	$595.40
Rate for Payer: Aetna Commercial	$418.79
Rate for Payer: Aetna Medicare	$325.03
Rate for Payer: Aetna New Business (MI Preferred)	$450.04
Rate for Payer: Aetna New Business (MI Preferred)	$418.79
Rate for Payer: BCBS Complete	$366.40
Rate for Payer: BCBS MAPPO	$312.53
Rate for Payer: BCN Medicare Advantage	$312.53
Rate for Payer: Cash Price	$732.80
Rate for Payer: Cash Price	$732.80
Rate for Payer: Cofinity Commercial	$450.04
Rate for Payer: Cofinity Commercial	$418.79
Rate for Payer: Health Alliance Plan Medicare Advantage	$312.53
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$328.16
Rate for Payer: Nomi Health Commercial	$375.04
Rate for Payer: PACE SWMI	$312.53
Rate for Payer: PHP Commercial	$437.54
Rate for Payer: PHP Medicare Advantage	$312.53
Rate for Payer: Priority Health Cigna Priority Health	$595.40
Rate for Payer: Priority Health Medicare	$312.53
Rate for Payer: UHC Dual Complete DSNP	$312.53
Rate for Payer: UHC Medicare Advantage	$312.53
Rate for Payer: UMR Bronson Commercial	$421.36

PR PERCUTANEOUS VERTEBROPLASTY EA ADDL THRC/LMBR

Professional

Both

$719.00

Service Code	HCPCS 22522
Min. Negotiated Rate	$287.60
Max. Negotiated Rate	$467.35
Rate for Payer: Aetna Medicare	$359.50
Rate for Payer: BCBS Complete	$287.60
Rate for Payer: Cash Price	$575.20
Rate for Payer: Priority Health Cigna Priority Health	$467.35
Rate for Payer: UMR Bronson Commercial	$330.74

PR PERCUTANEOUS VERTEBROPLASTY LUMBAR W/WO BNE BX

Professional

Both

$5,744.00

Service Code	HCPCS 22521
Min. Negotiated Rate	$2,297.60
Max. Negotiated Rate	$3,733.60
Rate for Payer: Aetna Medicare	$2,872.00
Rate for Payer: BCBS Complete	$2,297.60
Rate for Payer: Cash Price	$4,595.20
Rate for Payer: Priority Health Cigna Priority Health	$3,733.60
Rate for Payer: UMR Bronson Commercial	$2,642.24

PR PERCUTANEOUS VERTEBROPLSTY THORACIC W/WO BONE BX

Professional

Both

$7,841.00

Service Code	HCPCS 22520
Min. Negotiated Rate	$3,136.40
Max. Negotiated Rate	$5,096.65
Rate for Payer: Aetna Medicare	$3,920.50
Rate for Payer: BCBS Complete	$3,136.40
Rate for Payer: Cash Price	$6,272.80
Rate for Payer: Priority Health Cigna Priority Health	$5,096.65
Rate for Payer: UMR Bronson Commercial	$3,606.86

PR PERCUT DILATN RENAL TRACT

Professional

Both

$347.00

Service Code	HCPCS 50395
Min. Negotiated Rate	$138.80
Max. Negotiated Rate	$225.55
Rate for Payer: Aetna Medicare	$173.50
Rate for Payer: BCBS Complete	$138.80
Rate for Payer: Cash Price	$277.60
Rate for Payer: Priority Health Cigna Priority Health	$225.55
Rate for Payer: UMR Bronson Commercial	$159.62

PR PERCUT INSERT KIDNEY CATH/DRAIN

Professional

Both

$365.00

Service Code	HCPCS 50392
Min. Negotiated Rate	$146.00
Max. Negotiated Rate	$237.25
Rate for Payer: Aetna Medicare	$182.50
Rate for Payer: BCBS Complete	$146.00
Rate for Payer: Cash Price	$292.00
Rate for Payer: Priority Health Cigna Priority Health	$237.25
Rate for Payer: UMR Bronson Commercial	$167.90

PR PERC VERTEB AUGMENT/ KYPHOPLAST, EA ADD

Professional

Both

$505.00

Service Code	HCPCS 22525
Min. Negotiated Rate	$202.00
Max. Negotiated Rate	$328.25
Rate for Payer: Aetna Medicare	$252.50
Rate for Payer: BCBS Complete	$202.00
Rate for Payer: Cash Price	$404.00
Rate for Payer: Priority Health Cigna Priority Health	$328.25
Rate for Payer: UMR Bronson Commercial	$232.30

PR PERC VERTEB AUGMENT/ KYPHOPLAST, LUMBAR

Professional

Both

$1,075.00

Service Code	HCPCS 22524
Min. Negotiated Rate	$430.00
Max. Negotiated Rate	$698.75
Rate for Payer: Aetna Medicare	$537.50
Rate for Payer: BCBS Complete	$430.00
Rate for Payer: Cash Price	$860.00
Rate for Payer: Priority Health Cigna Priority Health	$698.75
Rate for Payer: UMR Bronson Commercial	$494.50

PR PERC VERTEB AUGMENT/ KYPHOPLAST, THOR

Professional

Both

$1,141.00

Service Code	HCPCS 22523
Min. Negotiated Rate	$456.40
Max. Negotiated Rate	$741.65
Rate for Payer: Aetna Medicare	$570.50
Rate for Payer: BCBS Complete	$456.40
Rate for Payer: Cash Price	$912.80
Rate for Payer: Priority Health Cigna Priority Health	$741.65
Rate for Payer: UMR Bronson Commercial	$524.86

PR PEREYRA PX W/ANTERIOR COLPORRHAPHY

Professional

Both

$2,213.00

Service Code	HCPCS 57289
Min. Negotiated Rate	$758.08
Max. Negotiated Rate	$1,438.45
Rate for Payer: Aetna Commercial	$1,015.83
Rate for Payer: Aetna Medicare	$788.40
Rate for Payer: Aetna New Business (MI Preferred)	$1,015.83
Rate for Payer: Aetna New Business (MI Preferred)	$1,091.64
Rate for Payer: BCBS Complete	$885.20
Rate for Payer: BCBS MAPPO	$758.08
Rate for Payer: BCN Medicare Advantage	$758.08
Rate for Payer: Cash Price	$1,770.40
Rate for Payer: Cash Price	$1,770.40
Rate for Payer: Cofinity Commercial	$1,015.83
Rate for Payer: Cofinity Commercial	$1,091.64
Rate for Payer: Health Alliance Plan Medicare Advantage	$758.08
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$795.98
Rate for Payer: Nomi Health Commercial	$909.70
Rate for Payer: PACE SWMI	$758.08
Rate for Payer: PHP Commercial	$1,061.31
Rate for Payer: PHP Medicare Advantage	$758.08
Rate for Payer: Priority Health Cigna Priority Health	$1,438.45
Rate for Payer: Priority Health Medicare	$758.08
Rate for Payer: UHC Dual Complete DSNP	$758.08
Rate for Payer: UHC Medicare Advantage	$758.08
Rate for Payer: UMR Bronson Commercial	$1,017.98

PR PERICARDIOCENTESIS INITIAL

Professional

Both

$451.00

Service Code	HCPCS 33010
Min. Negotiated Rate	$180.40
Max. Negotiated Rate	$293.15
Rate for Payer: Aetna Medicare	$225.50
Rate for Payer: BCBS Complete	$180.40
Rate for Payer: Cash Price	$360.80
Rate for Payer: Priority Health Cigna Priority Health	$293.15
Rate for Payer: UMR Bronson Commercial	$207.46

PR PERICARDIOCENTESIS SUBSEQUENT

Professional

Both

$450.00

Service Code	HCPCS 33011
Min. Negotiated Rate	$180.00
Max. Negotiated Rate	$292.50
Rate for Payer: Aetna Medicare	$225.00
Rate for Payer: BCBS Complete	$180.00
Rate for Payer: Cash Price	$360.00
Rate for Payer: Priority Health Cigna Priority Health	$292.50
Rate for Payer: UMR Bronson Commercial	$207.00

PR PERICARDIOCENTESIS W/IMG GUIDANCE WHEN PERFORMED

Professional

Both

$495.00

Service Code	HCPCS 33016
Min. Negotiated Rate	$198.00
Max. Negotiated Rate	$322.44
Rate for Payer: Aetna Commercial	$300.05
Rate for Payer: Aetna Medicare	$232.88
Rate for Payer: Aetna New Business (MI Preferred)	$322.44
Rate for Payer: Aetna New Business (MI Preferred)	$300.05
Rate for Payer: BCBS Complete	$198.00
Rate for Payer: BCBS MAPPO	$223.92
Rate for Payer: BCN Medicare Advantage	$223.92
Rate for Payer: Cash Price	$396.00
Rate for Payer: Cash Price	$396.00
Rate for Payer: Cofinity Commercial	$300.05
Rate for Payer: Cofinity Commercial	$322.44
Rate for Payer: Health Alliance Plan Medicare Advantage	$223.92
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$235.12
Rate for Payer: Nomi Health Commercial	$268.70
Rate for Payer: PACE SWMI	$223.92
Rate for Payer: PHP Commercial	$313.49
Rate for Payer: PHP Medicare Advantage	$223.92
Rate for Payer: Priority Health Cigna Priority Health	$321.75
Rate for Payer: Priority Health Medicare	$223.92
Rate for Payer: UHC Dual Complete DSNP	$223.92
Rate for Payer: UHC Medicare Advantage	$223.92
Rate for Payer: UMR Bronson Commercial	$227.70

PR PERICARDIOTOMY REMOVAL CLOT/FOREIGN BODY PRIMARY

Professional

Both

$2,657.00

Service Code	HCPCS 33020
Min. Negotiated Rate	$795.71
Max. Negotiated Rate	$1,727.05
Rate for Payer: Aetna Commercial	$1,066.25
Rate for Payer: Aetna Medicare	$827.54
Rate for Payer: Aetna New Business (MI Preferred)	$1,145.82
Rate for Payer: Aetna New Business (MI Preferred)	$1,066.25
Rate for Payer: BCBS Complete	$1,062.80
Rate for Payer: BCBS MAPPO	$795.71
Rate for Payer: BCN Medicare Advantage	$795.71
Rate for Payer: Cash Price	$2,125.60
Rate for Payer: Cash Price	$2,125.60
Rate for Payer: Cofinity Commercial	$1,145.82
Rate for Payer: Cofinity Commercial	$1,066.25
Rate for Payer: Health Alliance Plan Medicare Advantage	$795.71
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$835.50
Rate for Payer: Nomi Health Commercial	$954.85
Rate for Payer: PACE SWMI	$795.71
Rate for Payer: PHP Commercial	$1,113.99
Rate for Payer: PHP Medicare Advantage	$795.71
Rate for Payer: Priority Health Cigna Priority Health	$1,727.05
Rate for Payer: Priority Health Medicare	$795.71
Rate for Payer: UHC Dual Complete DSNP	$795.71
Rate for Payer: UHC Medicare Advantage	$795.71
Rate for Payer: UMR Bronson Commercial	$1,222.22

PR PERI-IMPLANT CAPSULECTOMY BREAST COMPLETE

Professional

Both

$2,152.00

Service Code	HCPCS 19371
Min. Negotiated Rate	$683.82
Max. Negotiated Rate	$1,398.80
Rate for Payer: Aetna Commercial	$916.32
Rate for Payer: Aetna Medicare	$711.17
Rate for Payer: Aetna New Business (MI Preferred)	$984.70
Rate for Payer: Aetna New Business (MI Preferred)	$916.32
Rate for Payer: BCBS Complete	$860.80
Rate for Payer: BCBS MAPPO	$683.82
Rate for Payer: BCN Medicare Advantage	$683.82
Rate for Payer: Cash Price	$1,721.60
Rate for Payer: Cash Price	$1,721.60
Rate for Payer: Cofinity Commercial	$984.70
Rate for Payer: Cofinity Commercial	$916.32
Rate for Payer: Health Alliance Plan Medicare Advantage	$683.82
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$718.01
Rate for Payer: Nomi Health Commercial	$820.58
Rate for Payer: PACE SWMI	$683.82
Rate for Payer: PHP Commercial	$957.35
Rate for Payer: PHP Medicare Advantage	$683.82
Rate for Payer: Priority Health Cigna Priority Health	$1,398.80
Rate for Payer: Priority Health Medicare	$683.82
Rate for Payer: UHC Dual Complete DSNP	$683.82
Rate for Payer: UHC Medicare Advantage	$683.82
Rate for Payer: UMR Bronson Commercial	$989.92

PR PERINEOPLASTY RPR PERINEUM NONOBSTETRICAL SPX

Professional

Both

$916.00

Service Code	HCPCS 56810
Min. Negotiated Rate	$259.54
Max. Negotiated Rate	$595.40
Rate for Payer: Aetna Commercial	$347.78
Rate for Payer: Aetna Medicare	$269.92
Rate for Payer: Aetna New Business (MI Preferred)	$373.74
Rate for Payer: Aetna New Business (MI Preferred)	$347.78
Rate for Payer: BCBS Complete	$366.40
Rate for Payer: BCBS MAPPO	$259.54
Rate for Payer: BCN Medicare Advantage	$259.54
Rate for Payer: Cash Price	$732.80
Rate for Payer: Cash Price	$732.80
Rate for Payer: Cofinity Commercial	$373.74
Rate for Payer: Cofinity Commercial	$347.78
Rate for Payer: Health Alliance Plan Medicare Advantage	$259.54
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$272.52
Rate for Payer: Nomi Health Commercial	$311.45
Rate for Payer: PACE SWMI	$259.54
Rate for Payer: PHP Commercial	$363.36
Rate for Payer: PHP Medicare Advantage	$259.54
Rate for Payer: Priority Health Cigna Priority Health	$595.40
Rate for Payer: Priority Health Medicare	$259.54
Rate for Payer: UHC Dual Complete DSNP	$259.54
Rate for Payer: UHC Medicare Advantage	$259.54
Rate for Payer: UMR Bronson Commercial	$421.36

PR PERIODIC PREVENTIVE MED ESTABLISHED PATIENT <1Y

Professional

Both

$154.00

Service Code	HCPCS 99391
Min. Negotiated Rate	$61.60
Max. Negotiated Rate	$100.10
Rate for Payer: Aetna Medicare	$77.00
Rate for Payer: BCBS Complete	$61.60
Rate for Payer: Cash Price	$123.20
Rate for Payer: Priority Health Cigna Priority Health	$100.10
Rate for Payer: UMR Bronson Commercial	$70.84

PR PERIODIC PREVENTIVE MED EST PATIENT 12-17YRS

Professional

Both

$166.00

Service Code	HCPCS 99394
Min. Negotiated Rate	$66.40
Max. Negotiated Rate	$107.90
Rate for Payer: Aetna Medicare	$83.00
Rate for Payer: BCBS Complete	$66.40
Rate for Payer: Cash Price	$132.80
Rate for Payer: Priority Health Cigna Priority Health	$107.90
Rate for Payer: UMR Bronson Commercial	$76.36

PR PERIODIC PREVENTIVE MED EST PATIENT 1-4YRS

Professional

Both

$165.00

Service Code	HCPCS 99392
Min. Negotiated Rate	$66.00
Max. Negotiated Rate	$107.25
Rate for Payer: Aetna Medicare	$82.50
Rate for Payer: BCBS Complete	$66.00
Rate for Payer: Cash Price	$132.00
Rate for Payer: Priority Health Cigna Priority Health	$107.25
Rate for Payer: UMR Bronson Commercial	$75.90

PR PERIODIC PREVENTIVE MED EST PATIENT 18-39 YRS

Professional

Both

$169.00

Service Code	HCPCS 99395
Min. Negotiated Rate	$67.60
Max. Negotiated Rate	$109.85
Rate for Payer: Aetna Medicare	$84.50
Rate for Payer: BCBS Complete	$67.60
Rate for Payer: Cash Price	$135.20
Rate for Payer: Priority Health Cigna Priority Health	$109.85
Rate for Payer: UMR Bronson Commercial	$77.74

PR PERIODIC PREVENTIVE MED EST PATIENT 40-64YRS

Professional

Both

$182.00

Service Code	HCPCS 99396
Min. Negotiated Rate	$72.80
Max. Negotiated Rate	$118.30
Rate for Payer: Aetna Medicare	$91.00
Rate for Payer: BCBS Complete	$72.80
Rate for Payer: Cash Price	$145.60
Rate for Payer: Priority Health Cigna Priority Health	$118.30
Rate for Payer: UMR Bronson Commercial	$83.72

PR PERIODIC PREVENTIVE MED EST PATIENT 5-11YRS

Professional

Both

$152.00

Service Code	HCPCS 99393
Min. Negotiated Rate	$60.80
Max. Negotiated Rate	$98.80
Rate for Payer: Aetna Medicare	$76.00
Rate for Payer: BCBS Complete	$60.80
Rate for Payer: Cash Price	$121.60
Rate for Payer: Priority Health Cigna Priority Health	$98.80
Rate for Payer: UMR Bronson Commercial	$69.92

PR PERIODIC PREVENTIVE MED EST PATIENT 65YRS& OLDER

Professional

Both

$196.00

Service Code	HCPCS 99397
Min. Negotiated Rate	$78.40
Max. Negotiated Rate	$127.40
Rate for Payer: Aetna Medicare	$98.00
Rate for Payer: BCBS Complete	$78.40
Rate for Payer: Cash Price	$156.80
Rate for Payer: Priority Health Cigna Priority Health	$127.40
Rate for Payer: UMR Bronson Commercial	$90.16

Know your out-of-pocket cost for care.

All Charges