Bronson Methodist Hospital

All Charges

Charge

Type

Setting

Price

PR APPLICATION CAST HAND & LOWER FOREARM GAUNTLET

Professional

Both

$185.00

Service Code	HCPCS 29085
Min. Negotiated Rate	$43.45
Max. Negotiated Rate	$1,099.39
Rate for Payer: Aetna Commercial	$87.81
Rate for Payer: BCBS Complete	$45.62
Rate for Payer: BCBS Trust/PPO	$1,099.39
Rate for Payer: Cash Price	$148.00
Rate for Payer: Cash Price	$148.00
Rate for Payer: Meridian Medicaid	$45.62
Rate for Payer: Priority Health Choice Medicaid	$43.45
Rate for Payer: Priority Health Cigna Priority Health	$129.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$102.64
Rate for Payer: Priority Health Narrow Network	$102.64
Rate for Payer: Priority Health SBD	$102.64
Rate for Payer: UMR Bronson Commercial	$85.10

PR APPLICATION CAST SHOULDER HAND LONG ARM

Professional

Both

$254.00

Service Code	HCPCS 29065
Min. Negotiated Rate	$43.88
Max. Negotiated Rate	$1,191.32
Rate for Payer: Aetna Commercial	$89.13
Rate for Payer: BCBS Complete	$46.07
Rate for Payer: BCBS Trust/PPO	$1,191.32
Rate for Payer: Cash Price	$203.20
Rate for Payer: Cash Price	$203.20
Rate for Payer: Meridian Medicaid	$46.07
Rate for Payer: Priority Health Choice Medicaid	$43.88
Rate for Payer: Priority Health Cigna Priority Health	$177.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$104.17
Rate for Payer: Priority Health Narrow Network	$104.17
Rate for Payer: Priority Health SBD	$104.17
Rate for Payer: UMR Bronson Commercial	$116.84

PR APPLICATION CYLINDER CAST THIGH ANKLE

Professional

Both

$247.00

Service Code	HCPCS 29365
Min. Negotiated Rate	$56.45
Max. Negotiated Rate	$701.58
Rate for Payer: Aetna Commercial	$114.22
Rate for Payer: BCBS Complete	$59.27
Rate for Payer: BCBS Trust/PPO	$701.58
Rate for Payer: Cash Price	$197.60
Rate for Payer: Cash Price	$197.60
Rate for Payer: Meridian Medicaid	$59.27
Rate for Payer: Priority Health Choice Medicaid	$56.45
Rate for Payer: Priority Health Cigna Priority Health	$172.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$132.77
Rate for Payer: Priority Health Narrow Network	$132.77
Rate for Payer: Priority Health SBD	$132.77
Rate for Payer: UMR Bronson Commercial	$113.62

PR APPLICATION FINGER SPLINT DYNAMIC

Professional

Both

$103.00

Service Code	HCPCS 29131
Min. Negotiated Rate	$22.15
Max. Negotiated Rate	$2,121.65
Rate for Payer: Aetna Commercial	$45.51
Rate for Payer: BCBS Complete	$23.26
Rate for Payer: BCBS Trust/PPO	$2,121.65
Rate for Payer: Cash Price	$82.40
Rate for Payer: Cash Price	$82.40
Rate for Payer: Meridian Medicaid	$23.26
Rate for Payer: Priority Health Choice Medicaid	$22.15
Rate for Payer: Priority Health Cigna Priority Health	$72.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$53.10
Rate for Payer: Priority Health Narrow Network	$53.10
Rate for Payer: Priority Health SBD	$53.10
Rate for Payer: UMR Bronson Commercial	$47.38

PR APPLICATION FINGER SPLINT STATIC

Professional

Both

$92.00

Service Code	HCPCS 29130
Min. Negotiated Rate	$18.53
Max. Negotiated Rate	$2,436.52
Rate for Payer: Aetna Commercial	$38.86
Rate for Payer: BCBS Complete	$19.46
Rate for Payer: BCBS Trust/PPO	$2,436.52
Rate for Payer: Cash Price	$73.60
Rate for Payer: Cash Price	$73.60
Rate for Payer: Meridian Medicaid	$19.46
Rate for Payer: Priority Health Choice Medicaid	$18.53
Rate for Payer: Priority Health Cigna Priority Health	$64.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$44.94
Rate for Payer: Priority Health Narrow Network	$44.94
Rate for Payer: Priority Health SBD	$44.94
Rate for Payer: UMR Bronson Commercial	$42.32

PR APPLICATION HALO CRANIAL INCLUDING REMOVAL

Professional

Both

$1,077.00

Service Code	HCPCS 20661
Min. Negotiated Rate	$342.08
Max. Negotiated Rate	$32,076.33
Rate for Payer: Aetna Commercial	$671.47
Rate for Payer: BCBS Complete	$359.18
Rate for Payer: BCBS Trust/PPO	$32,076.33
Rate for Payer: Cash Price	$861.60
Rate for Payer: Cash Price	$861.60
Rate for Payer: Meridian Medicaid	$359.18
Rate for Payer: Priority Health Choice Medicaid	$342.08
Rate for Payer: Priority Health Cigna Priority Health	$753.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$798.66
Rate for Payer: Priority Health Narrow Network	$798.66
Rate for Payer: Priority Health SBD	$798.66
Rate for Payer: UMR Bronson Commercial	$495.42

PR APPLICATION HIP SPICA CAST 1 LEG

Professional

Both

$480.00

Service Code	HCPCS 29305
Min. Negotiated Rate	$101.81
Max. Negotiated Rate	$1,986.41
Rate for Payer: Aetna Commercial	$208.12
Rate for Payer: BCBS Complete	$106.90
Rate for Payer: BCBS Trust/PPO	$1,986.41
Rate for Payer: Cash Price	$384.00
Rate for Payer: Cash Price	$384.00
Rate for Payer: Meridian Medicaid	$106.90
Rate for Payer: Priority Health Choice Medicaid	$101.81
Rate for Payer: Priority Health Cigna Priority Health	$336.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$241.03
Rate for Payer: Priority Health Narrow Network	$241.03
Rate for Payer: Priority Health SBD	$241.03
Rate for Payer: UMR Bronson Commercial	$220.80

PR APPLICATION INTERVERTEBRAL BIOMECHANICAL DEVICE

Professional

Both

$2,042.00

Service Code	HCPCS 22851
Min. Negotiated Rate	$816.80
Max. Negotiated Rate	$1,429.40
Rate for Payer: BCBS Complete	$816.80
Rate for Payer: Cash Price	$1,633.60
Rate for Payer: Priority Health Cigna Priority Health	$1,429.40
Rate for Payer: UMR Bronson Commercial	$939.32

PR APPLICATION LONG ARM SPLINT SHOULDER HAND

Professional

Both

$162.00

Service Code	HCPCS 29105
Min. Negotiated Rate	$26.63
Max. Negotiated Rate	$950.41
Rate for Payer: Aetna Commercial	$57.05
Rate for Payer: BCBS Complete	$27.96
Rate for Payer: BCBS Trust/PPO	$950.41
Rate for Payer: Cash Price	$129.60
Rate for Payer: Cash Price	$129.60
Rate for Payer: Meridian Medicaid	$27.96
Rate for Payer: Priority Health Choice Medicaid	$26.63
Rate for Payer: Priority Health Cigna Priority Health	$113.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$64.35
Rate for Payer: Priority Health Narrow Network	$64.35
Rate for Payer: Priority Health SBD	$64.35
Rate for Payer: UMR Bronson Commercial	$74.52

PR APPLICATION LONG LEG CAST BRACE

Professional

Both

$272.00

Service Code	HCPCS 29358
Min. Negotiated Rate	$66.24
Max. Negotiated Rate	$190.40
Rate for Payer: Aetna Commercial	$136.06
Rate for Payer: BCBS Complete	$69.55
Rate for Payer: BCBS Trust/PPO	$104.08
Rate for Payer: Cash Price	$217.60
Rate for Payer: Cash Price	$217.60
Rate for Payer: Meridian Medicaid	$69.55
Rate for Payer: Priority Health Choice Medicaid	$66.24
Rate for Payer: Priority Health Cigna Priority Health	$190.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$156.76
Rate for Payer: Priority Health Narrow Network	$156.76
Rate for Payer: Priority Health SBD	$156.76
Rate for Payer: UMR Bronson Commercial	$125.12

PR APPLICATION LONG LEG CAST THIGH-TOE

Professional

Both

$276.00

Service Code	HCPCS 29345
Min. Negotiated Rate	$63.47
Max. Negotiated Rate	$221.36
Rate for Payer: Aetna Commercial	$131.58
Rate for Payer: BCBS Complete	$66.64
Rate for Payer: BCBS Trust/PPO	$221.36
Rate for Payer: Cash Price	$220.80
Rate for Payer: Cash Price	$220.80
Rate for Payer: Meridian Medicaid	$66.64
Rate for Payer: Priority Health Choice Medicaid	$63.47
Rate for Payer: Priority Health Cigna Priority Health	$193.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$151.66
Rate for Payer: Priority Health Narrow Network	$151.66
Rate for Payer: Priority Health SBD	$151.66
Rate for Payer: UMR Bronson Commercial	$126.96

PR APPLICATION LONG LEG CAST WALKER/AMBULATORY TYPE

Professional

Both

$247.00

Service Code	HCPCS 29355
Min. Negotiated Rate	$68.16
Max. Negotiated Rate	$585.88
Rate for Payer: Aetna Commercial	$142.12
Rate for Payer: BCBS Complete	$71.57
Rate for Payer: BCBS Trust/PPO	$585.88
Rate for Payer: Cash Price	$197.60
Rate for Payer: Cash Price	$197.60
Rate for Payer: Meridian Medicaid	$71.57
Rate for Payer: Priority Health Choice Medicaid	$68.16
Rate for Payer: Priority Health Cigna Priority Health	$172.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$161.87
Rate for Payer: Priority Health Narrow Network	$161.87
Rate for Payer: Priority Health SBD	$161.87
Rate for Payer: UMR Bronson Commercial	$113.62

PR APPLICATION LONG LEG SPLINT THIGH ANKLE/TOES

Professional

Both

$134.00

Service Code	HCPCS 29505
Min. Negotiated Rate	$33.65
Max. Negotiated Rate	$1,145.35
Rate for Payer: Aetna Commercial	$68.11
Rate for Payer: BCBS Complete	$35.33
Rate for Payer: BCBS Trust/PPO	$1,145.35
Rate for Payer: Cash Price	$107.20
Rate for Payer: Cash Price	$107.20
Rate for Payer: Meridian Medicaid	$35.33
Rate for Payer: Priority Health Choice Medicaid	$33.65
Rate for Payer: Priority Health Cigna Priority Health	$93.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$79.16
Rate for Payer: Priority Health Narrow Network	$79.16
Rate for Payer: Priority Health SBD	$79.16
Rate for Payer: UMR Bronson Commercial	$61.64

PR APPLICATION MODALITY 1/> AREAS HOT/COLD PACKS

Professional

Both

$8.00

Service Code	HCPCS 97010
Min. Negotiated Rate	$3.20
Max. Negotiated Rate	$1,245.73
Rate for Payer: Aetna Commercial	$4.45
Rate for Payer: BCBS Complete	$3.20
Rate for Payer: BCBS Trust/PPO	$1,245.73
Rate for Payer: Cash Price	$6.40
Rate for Payer: Cash Price	$6.40
Rate for Payer: Priority Health Cigna Priority Health	$5.60
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	$3.68

PR APPLICATION MODALITY 1/> AREAS WHIRLPOOL

Professional

Both

$33.00

Service Code	HCPCS 97022
Min. Negotiated Rate	$12.81
Max. Negotiated Rate	$1,929.88
Rate for Payer: Aetna Commercial	$12.81
Rate for Payer: BCBS Complete	$13.20
Rate for Payer: BCBS Trust/PPO	$1,929.88
Rate for Payer: Cash Price	$26.40
Rate for Payer: Cash Price	$26.40
Rate for Payer: Priority Health Cigna Priority Health	$23.10
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	$15.18

PR APPLICATION MULTIPLANE EXTERNAL FIXATION SYSTEM

Professional

Both

$1,887.00

Service Code	HCPCS 20692
Min. Negotiated Rate	$726.12
Max. Negotiated Rate	$3,350.93
Rate for Payer: Aetna Commercial	$1,488.90
Rate for Payer: BCBS Complete	$762.43
Rate for Payer: BCBS Trust/PPO	$3,350.93
Rate for Payer: Cash Price	$1,509.60
Rate for Payer: Cash Price	$1,509.60
Rate for Payer: Meridian Medicaid	$762.43
Rate for Payer: Priority Health Choice Medicaid	$726.12
Rate for Payer: Priority Health Cigna Priority Health	$1,320.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,717.32
Rate for Payer: Priority Health Narrow Network	$1,717.32
Rate for Payer: Priority Health SBD	$1,717.32
Rate for Payer: UMR Bronson Commercial	$868.02

PR APPLICATION OF SURFACE NEUROSTIMULATOR

Professional

Both

$32.00

Service Code	HCPCS 64550
Min. Negotiated Rate	$12.80
Max. Negotiated Rate	$22.40
Rate for Payer: BCBS Complete	$12.80
Rate for Payer: Cash Price	$25.60
Rate for Payer: Priority Health Cigna Priority Health	$22.40
Rate for Payer: UMR Bronson Commercial	$14.72

PR APPLICATION PATELLAR TENDON BEARING CAST

Professional

Both

$342.00

Service Code	HCPCS 29435
Min. Negotiated Rate	$55.59
Max. Negotiated Rate	$761.81
Rate for Payer: Aetna Commercial	$107.32
Rate for Payer: BCBS Complete	$58.37
Rate for Payer: BCBS Trust/PPO	$761.81
Rate for Payer: Cash Price	$273.60
Rate for Payer: Cash Price	$273.60
Rate for Payer: Meridian Medicaid	$58.37
Rate for Payer: Priority Health Choice Medicaid	$55.59
Rate for Payer: Priority Health Cigna Priority Health	$239.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$123.07
Rate for Payer: Priority Health Narrow Network	$123.07
Rate for Payer: Priority Health SBD	$123.07
Rate for Payer: UMR Bronson Commercial	$157.32

PR APPLICATION RIGID TOTAL CONTACT LEG CAST

Professional

Both

$370.00

Service Code	HCPCS 29445
Min. Negotiated Rate	$62.84
Max. Negotiated Rate	$1,242.56
Rate for Payer: Aetna Commercial	$133.87
Rate for Payer: BCBS Complete	$65.98
Rate for Payer: BCBS Trust/PPO	$1,242.56
Rate for Payer: Cash Price	$296.00
Rate for Payer: Cash Price	$296.00
Rate for Payer: Meridian Medicaid	$65.98
Rate for Payer: Priority Health Choice Medicaid	$62.84
Rate for Payer: Priority Health Cigna Priority Health	$259.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$148.60
Rate for Payer: Priority Health Narrow Network	$148.60
Rate for Payer: Priority Health SBD	$148.60
Rate for Payer: UMR Bronson Commercial	$170.20

PR APPLICATION SHORT ARM SPLINT DYNAMIC

Professional

Both

$188.00

Service Code	HCPCS 29126
Min. Negotiated Rate	$31.74
Max. Negotiated Rate	$1,873.35
Rate for Payer: Aetna Commercial	$63.68
Rate for Payer: BCBS Complete	$33.33
Rate for Payer: BCBS Trust/PPO	$1,873.35
Rate for Payer: Cash Price	$150.40
Rate for Payer: Cash Price	$150.40
Rate for Payer: Meridian Medicaid	$33.33
Rate for Payer: Priority Health Choice Medicaid	$31.74
Rate for Payer: Priority Health Cigna Priority Health	$131.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$75.06
Rate for Payer: Priority Health Narrow Network	$75.06
Rate for Payer: Priority Health SBD	$75.06
Rate for Payer: UMR Bronson Commercial	$86.48

PR APPLICATION SHORT ARM SPLINT FOREARM-HAND STATIC

Professional

Both

$139.00

Service Code	HCPCS 29125
Min. Negotiated Rate	$25.99
Max. Negotiated Rate	$1,005.88
Rate for Payer: Aetna Commercial	$52.16
Rate for Payer: BCBS Complete	$27.29
Rate for Payer: BCBS Trust/PPO	$1,005.88
Rate for Payer: Cash Price	$111.20
Rate for Payer: Cash Price	$111.20
Rate for Payer: Meridian Medicaid	$27.29
Rate for Payer: Priority Health Choice Medicaid	$25.99
Rate for Payer: Priority Health Cigna Priority Health	$97.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$61.78
Rate for Payer: Priority Health Narrow Network	$61.78
Rate for Payer: Priority Health SBD	$61.78
Rate for Payer: UMR Bronson Commercial	$63.94

PR APPLICATION SHORT LEG CAST BELOW KNEE-TOE

Professional

Both

$228.00

Service Code	HCPCS 29405
Min. Negotiated Rate	$37.70
Max. Negotiated Rate	$1,199.24
Rate for Payer: Aetna Commercial	$77.15
Rate for Payer: BCBS Complete	$39.58
Rate for Payer: BCBS Trust/PPO	$1,199.24
Rate for Payer: Cash Price	$182.40
Rate for Payer: Cash Price	$182.40
Rate for Payer: Meridian Medicaid	$39.58
Rate for Payer: Priority Health Choice Medicaid	$37.70
Rate for Payer: Priority Health Cigna Priority Health	$159.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$88.85
Rate for Payer: Priority Health Narrow Network	$88.85
Rate for Payer: Priority Health SBD	$88.85
Rate for Payer: UMR Bronson Commercial	$104.88

PR APPLICATION SHORT LEG CAST WALKING/AMBULATORY

Professional

Both

$266.00

Service Code	HCPCS 29425
Min. Negotiated Rate	$34.72
Max. Negotiated Rate	$925.58
Rate for Payer: Aetna Commercial	$71.91
Rate for Payer: BCBS Complete	$36.46
Rate for Payer: BCBS Trust/PPO	$925.58
Rate for Payer: Cash Price	$212.80
Rate for Payer: Cash Price	$212.80
Rate for Payer: Meridian Medicaid	$36.46
Rate for Payer: Priority Health Choice Medicaid	$34.72
Rate for Payer: Priority Health Cigna Priority Health	$186.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$82.22
Rate for Payer: Priority Health Narrow Network	$82.22
Rate for Payer: Priority Health SBD	$82.22
Rate for Payer: UMR Bronson Commercial	$122.36

PR APPLICATION SHORT LEG SPLINT CALF FOOT

Professional

Both

$124.00

Service Code	HCPCS 29515
Min. Negotiated Rate	$31.95
Max. Negotiated Rate	$1,249.96
Rate for Payer: Aetna Commercial	$64.78
Rate for Payer: BCBS Complete	$33.55
Rate for Payer: BCBS Trust/PPO	$1,249.96
Rate for Payer: Cash Price	$99.20
Rate for Payer: Cash Price	$99.20
Rate for Payer: Meridian Medicaid	$33.55
Rate for Payer: Priority Health Choice Medicaid	$31.95
Rate for Payer: Priority Health Cigna Priority Health	$86.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$75.06
Rate for Payer: Priority Health Narrow Network	$75.06
Rate for Payer: Priority Health SBD	$75.06
Rate for Payer: UMR Bronson Commercial	$57.04

PR APPLICATION TOPICAL FLUORIDE VARNISH BY PHS/QHP

Professional

Both

$34.00

Service Code	HCPCS 99188
Min. Negotiated Rate	$6.18
Max. Negotiated Rate	$413.66
Rate for Payer: Aetna Commercial	$11.43
Rate for Payer: BCBS Complete	$6.49
Rate for Payer: BCBS Trust/PPO	$413.66
Rate for Payer: Cash Price	$27.20
Rate for Payer: Cash Price	$27.20
Rate for Payer: Meridian Medicaid	$6.49
Rate for Payer: Priority Health Choice Medicaid	$6.18
Rate for Payer: Priority Health Cigna Priority Health	$23.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$13.03
Rate for Payer: Priority Health Narrow Network	$13.03
Rate for Payer: Priority Health SBD	$13.03
Rate for Payer: UMR Bronson Commercial	$15.64

Know your out-of-pocket cost for care.

All Charges