Bronson Methodist Hospital

All Charges

Charge

Type

Setting

Price

PR BIOPSY TONGUE ANTERIOR TWO-THIRDS

Professional

Both

$322.00

Service Code	HCPCS 41100
Min. Negotiated Rate	$69.01
Max. Negotiated Rate	$824.68
Rate for Payer: Aetna Commercial	$140.82
Rate for Payer: BCBS Complete	$72.46
Rate for Payer: BCBS Trust/PPO	$824.68
Rate for Payer: Cash Price	$257.60
Rate for Payer: Cash Price	$257.60
Rate for Payer: Meridian Medicaid	$72.46
Rate for Payer: Priority Health Choice Medicaid	$69.01
Rate for Payer: Priority Health Cigna Priority Health	$225.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$189.33
Rate for Payer: Priority Health Narrow Network	$189.33
Rate for Payer: Priority Health SBD	$189.33
Rate for Payer: UMR Bronson Commercial	$148.12

PR BIOPSY TONGUE POSTERIOR ONE-THIRD

Professional

Both

$298.00

Service Code	HCPCS 41105
Min. Negotiated Rate	$70.93
Max. Negotiated Rate	$609.66
Rate for Payer: Aetna Commercial	$144.46
Rate for Payer: BCBS Complete	$74.48
Rate for Payer: BCBS Trust/PPO	$609.66
Rate for Payer: Cash Price	$238.40
Rate for Payer: Cash Price	$238.40
Rate for Payer: Meridian Medicaid	$74.48
Rate for Payer: Priority Health Choice Medicaid	$70.93
Rate for Payer: Priority Health Cigna Priority Health	$208.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$194.03
Rate for Payer: Priority Health Narrow Network	$194.03
Rate for Payer: Priority Health SBD	$194.03
Rate for Payer: UMR Bronson Commercial	$137.08

PR BIOPSY URETHRA

Professional

Both

$378.00

Service Code	HCPCS 53200
Min. Negotiated Rate	$90.10
Max. Negotiated Rate	$364.00
Rate for Payer: Aetna Commercial	$181.70
Rate for Payer: BCBS Complete	$94.60
Rate for Payer: BCBS Trust/PPO	$364.00
Rate for Payer: Cash Price	$302.40
Rate for Payer: Cash Price	$302.40
Rate for Payer: Meridian Medicaid	$94.60
Rate for Payer: Priority Health Choice Medicaid	$90.10
Rate for Payer: Priority Health Cigna Priority Health	$264.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$225.33
Rate for Payer: Priority Health Narrow Network	$225.33
Rate for Payer: Priority Health SBD	$225.33
Rate for Payer: UMR Bronson Commercial	$173.88

PR BIOPSY VAGINAL MUCOSA EXTENSIVE

Professional

Both

$310.00

Service Code	HCPCS 57105
Min. Negotiated Rate	$94.79
Max. Negotiated Rate	$3,594.02
Rate for Payer: Aetna Commercial	$167.82
Rate for Payer: BCBS Complete	$99.53
Rate for Payer: BCBS Trust/PPO	$3,594.02
Rate for Payer: Cash Price	$248.00
Rate for Payer: Cash Price	$248.00
Rate for Payer: Meridian Medicaid	$99.53
Rate for Payer: Priority Health Choice Medicaid	$94.79
Rate for Payer: Priority Health Cigna Priority Health	$217.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$208.78
Rate for Payer: Priority Health Narrow Network	$208.78
Rate for Payer: Priority Health SBD	$208.78
Rate for Payer: UMR Bronson Commercial	$142.60

PR BIOPSY VAGINAL MUCOSA SIMPLE

Professional

Both

$166.00

Service Code	HCPCS 57100
Min. Negotiated Rate	$41.75
Max. Negotiated Rate	$3,206.78
Rate for Payer: Aetna Commercial	$78.63
Rate for Payer: BCBS Complete	$43.84
Rate for Payer: BCBS Trust/PPO	$3,206.78
Rate for Payer: Cash Price	$132.80
Rate for Payer: Cash Price	$132.80
Rate for Payer: Meridian Medicaid	$43.84
Rate for Payer: Priority Health Choice Medicaid	$41.75
Rate for Payer: Priority Health Cigna Priority Health	$116.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$91.84
Rate for Payer: Priority Health Narrow Network	$91.84
Rate for Payer: Priority Health SBD	$91.84
Rate for Payer: UMR Bronson Commercial	$76.36

PR BIOPSY VERTEBRAL BODY OPEN LUMBAR/CERVICAL

Professional

Both

$1,301.00

Service Code	HCPCS 20251
Min. Negotiated Rate	$106.88
Max. Negotiated Rate	$910.70
Rate for Payer: Aetna Commercial	$569.56
Rate for Payer: BCBS Complete	$283.14
Rate for Payer: BCBS Trust/PPO	$106.88
Rate for Payer: Cash Price	$1,040.80
Rate for Payer: Cash Price	$1,040.80
Rate for Payer: Meridian Medicaid	$283.14
Rate for Payer: Priority Health Choice Medicaid	$269.66
Rate for Payer: Priority Health Cigna Priority Health	$910.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$646.48
Rate for Payer: Priority Health Narrow Network	$646.48
Rate for Payer: Priority Health SBD	$646.48
Rate for Payer: UMR Bronson Commercial	$598.46

PR BIOPSY VERTEBRAL BODY OPEN THORACIC

Professional

Both

$787.00

Service Code	HCPCS 20250
Min. Negotiated Rate	$252.19
Max. Negotiated Rate	$595.41
Rate for Payer: Aetna Commercial	$521.70
Rate for Payer: BCBS Complete	$264.80
Rate for Payer: BCBS Trust/PPO	$556.70
Rate for Payer: Cash Price	$629.60
Rate for Payer: Cash Price	$629.60
Rate for Payer: Meridian Medicaid	$264.80
Rate for Payer: Priority Health Choice Medicaid	$252.19
Rate for Payer: Priority Health Cigna Priority Health	$550.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$595.41
Rate for Payer: Priority Health Narrow Network	$595.41
Rate for Payer: Priority Health SBD	$595.41
Rate for Payer: UMR Bronson Commercial	$362.02

PR BIOPSY VESTIBULE MOUTH

Professional

Both

$299.00

Service Code	HCPCS 40808
Min. Negotiated Rate	$57.30
Max. Negotiated Rate	$547.85
Rate for Payer: Aetna Commercial	$113.82
Rate for Payer: BCBS Complete	$60.16
Rate for Payer: BCBS Trust/PPO	$547.85
Rate for Payer: Cash Price	$239.20
Rate for Payer: Cash Price	$239.20
Rate for Payer: Meridian Medicaid	$60.16
Rate for Payer: Priority Health Choice Medicaid	$57.30
Rate for Payer: Priority Health Cigna Priority Health	$209.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$155.81
Rate for Payer: Priority Health Narrow Network	$155.81
Rate for Payer: Priority Health SBD	$155.81
Rate for Payer: UMR Bronson Commercial	$137.54

PR BIOPSY VULVA/PERINEUM 1 LESION SPX

Professional

Both

$299.00

Service Code	HCPCS 56605
Min. Negotiated Rate	$37.70
Max. Negotiated Rate	$2,173.43
Rate for Payer: Aetna Commercial	$70.93
Rate for Payer: BCBS Complete	$39.58
Rate for Payer: BCBS Trust/PPO	$2,173.43
Rate for Payer: Cash Price	$239.20
Rate for Payer: Cash Price	$239.20
Rate for Payer: Meridian Medicaid	$39.58
Rate for Payer: Priority Health Choice Medicaid	$37.70
Rate for Payer: Priority Health Cigna Priority Health	$209.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$83.80
Rate for Payer: Priority Health Narrow Network	$83.80
Rate for Payer: Priority Health SBD	$83.80
Rate for Payer: UMR Bronson Commercial	$137.54

PR BIOPSY VULVA/PERINEUM EACH ADDL LESION

Professional

Both

$188.00

Service Code	HCPCS 56606
Min. Negotiated Rate	$18.53
Max. Negotiated Rate	$1,893.96
Rate for Payer: Aetna Commercial	$35.11
Rate for Payer: BCBS Complete	$19.46
Rate for Payer: BCBS Trust/PPO	$1,893.96
Rate for Payer: Cash Price	$150.40
Rate for Payer: Cash Price	$150.40
Rate for Payer: Meridian Medicaid	$19.46
Rate for Payer: Priority Health Choice Medicaid	$18.53
Rate for Payer: Priority Health Cigna Priority Health	$131.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$41.66
Rate for Payer: Priority Health Narrow Network	$41.66
Rate for Payer: Priority Health SBD	$41.66
Rate for Payer: UMR Bronson Commercial	$86.48

PR BKBENCH PREPJ CADAVER DONOR HEART/LUNG ALLOGRAFT

Professional

Both

$661.00

Service Code	HCPCS 33933
Min. Negotiated Rate	$251.71
Max. Negotiated Rate	$1,305.43
Rate for Payer: Aetna Commercial	$536.72
Rate for Payer: BCBS Complete	$264.30
Rate for Payer: BCBS Trust/PPO	$1,305.43
Rate for Payer: Cash Price	$528.80
Rate for Payer: Cash Price	$528.80
Rate for Payer: Meridian Medicaid	$264.30
Rate for Payer: Priority Health Choice Medicaid	$251.71
Rate for Payer: Priority Health Cigna Priority Health	$462.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$635.15
Rate for Payer: Priority Health Narrow Network	$635.15
Rate for Payer: Priority Health SBD	$635.15
Rate for Payer: UMR Bronson Commercial	$304.06

PR BLADDER INSTILLATION ANTICARCINOGENIC AGENT

Professional

Both

$267.00

Service Code	HCPCS 51720
Min. Negotiated Rate	$27.48
Max. Negotiated Rate	$2,209.35
Rate for Payer: Aetna Commercial	$56.30
Rate for Payer: BCBS Complete	$28.85
Rate for Payer: BCBS Trust/PPO	$2,209.35
Rate for Payer: Cash Price	$213.60
Rate for Payer: Cash Price	$213.60
Rate for Payer: Meridian Medicaid	$28.85
Rate for Payer: Priority Health Choice Medicaid	$27.48
Rate for Payer: Priority Health Cigna Priority Health	$186.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$69.70
Rate for Payer: Priority Health Narrow Network	$69.70
Rate for Payer: Priority Health SBD	$69.70
Rate for Payer: UMR Bronson Commercial	$122.82

PR BLADDER PRESSURE MEASUREMENT DURING FILLING

Professional

Both

$686.00

Service Code	HCPCS 51726
Min. Negotiated Rate	$134.55
Max. Negotiated Rate	$3,274.93
Rate for Payer: Aetna Commercial	$380.17
Rate for Payer: BCBS Complete	$274.40
Rate for Payer: BCBS Trust/PPO	$3,274.93
Rate for Payer: Cash Price	$548.80
Rate for Payer: Cash Price	$548.80
Rate for Payer: Priority Health Cigna Priority Health	$480.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$134.55
Rate for Payer: Priority Health Narrow Network	$134.55
Rate for Payer: Priority Health SBD	$488.48
Rate for Payer: UMR Bronson Commercial	$315.56

PR BLD-DRV HEMATOP PROGEN CELL HRVG TRNSPLJ AUTOL

Professional

Both

$452.00

Service Code	HCPCS 38206
Min. Negotiated Rate	$51.97
Max. Negotiated Rate	$1,117.35
Rate for Payer: Aetna Commercial	$104.26
Rate for Payer: BCBS Complete	$54.57
Rate for Payer: BCBS Trust/PPO	$1,117.35
Rate for Payer: Cash Price	$361.60
Rate for Payer: Cash Price	$361.60
Rate for Payer: Meridian Medicaid	$54.57
Rate for Payer: Priority Health Choice Medicaid	$51.97
Rate for Payer: Priority Health Cigna Priority Health	$316.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$178.18
Rate for Payer: Priority Health Narrow Network	$178.18
Rate for Payer: Priority Health SBD	$178.18
Rate for Payer: UMR Bronson Commercial	$207.92

PR BLDR IRRIGATION SMPL LAVAGE &/INSTLJ

Professional

Both

$173.00

Service Code	HCPCS 51700
Min. Negotiated Rate	$18.96
Max. Negotiated Rate	$1,655.16
Rate for Payer: Aetna Commercial	$39.89
Rate for Payer: BCBS Complete	$19.91
Rate for Payer: BCBS Trust/PPO	$1,655.16
Rate for Payer: Cash Price	$138.40
Rate for Payer: Cash Price	$138.40
Rate for Payer: Meridian Medicaid	$19.91
Rate for Payer: Priority Health Choice Medicaid	$18.96
Rate for Payer: Priority Health Cigna Priority Health	$121.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$48.09
Rate for Payer: Priority Health Narrow Network	$48.09
Rate for Payer: Priority Health SBD	$48.09
Rate for Payer: UMR Bronson Commercial	$79.58

PR BLEPHAROPLASTY LOWER EYELID HERNIATED FAT PAD

Professional

Both

$900.00

Service Code	HCPCS 15821
Min. Negotiated Rate	$312.59
Max. Negotiated Rate	$671.64
Rate for Payer: Aetna Commercial	$582.43
Rate for Payer: BCBS Complete	$369.24
Rate for Payer: BCBS Trust/PPO	$312.59
Rate for Payer: Cash Price	$720.00
Rate for Payer: Cash Price	$720.00
Rate for Payer: Meridian Medicaid	$369.24
Rate for Payer: Priority Health Choice Medicaid	$351.66
Rate for Payer: Priority Health Cigna Priority Health	$630.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$671.64
Rate for Payer: Priority Health Narrow Network	$671.64
Rate for Payer: Priority Health SBD	$671.64
Rate for Payer: UMR Bronson Commercial	$414.00

PR BLEPHAROPLASTY UPPER EYELID

Professional

Both

$925.00

Service Code	HCPCS 15822
Min. Negotiated Rate	$31.71
Max. Negotiated Rate	$647.50
Rate for Payer: Aetna Commercial	$422.37
Rate for Payer: BCBS Complete	$268.16
Rate for Payer: BCBS Trust/PPO	$31.71
Rate for Payer: Cash Price	$740.00
Rate for Payer: Cash Price	$740.00
Rate for Payer: Meridian Medicaid	$268.16
Rate for Payer: Priority Health Choice Medicaid	$255.39
Rate for Payer: Priority Health Cigna Priority Health	$647.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$488.73
Rate for Payer: Priority Health Narrow Network	$488.73
Rate for Payer: Priority Health SBD	$488.73
Rate for Payer: UMR Bronson Commercial	$425.50

PR BLEPHAROPLASTY UPPER EYELID W/EXCESSIVE SKIN

Professional

Both

$900.00

Service Code	HCPCS 15823
Min. Negotiated Rate	$46.61
Max. Negotiated Rate	$672.45
Rate for Payer: Aetna Commercial	$584.27
Rate for Payer: BCBS Complete	$369.47
Rate for Payer: BCBS Trust/PPO	$46.61
Rate for Payer: Cash Price	$720.00
Rate for Payer: Cash Price	$720.00
Rate for Payer: Meridian Medicaid	$369.47
Rate for Payer: Priority Health Choice Medicaid	$351.88
Rate for Payer: Priority Health Cigna Priority Health	$630.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$672.45
Rate for Payer: Priority Health Narrow Network	$672.45
Rate for Payer: Priority Health SBD	$672.45
Rate for Payer: UMR Bronson Commercial	$414.00

PR BLEPHAROTOMY DRAINAGE ABSCESS EYELID

Professional

Both

$434.00

Service Code	HCPCS 67700
Min. Negotiated Rate	$73.91
Max. Negotiated Rate	$498.19
Rate for Payer: Aetna Commercial	$149.98
Rate for Payer: BCBS Complete	$77.61
Rate for Payer: BCBS Trust/PPO	$498.19
Rate for Payer: Cash Price	$347.20
Rate for Payer: Cash Price	$347.20
Rate for Payer: Meridian Medicaid	$77.61
Rate for Payer: Priority Health Choice Medicaid	$73.91
Rate for Payer: Priority Health Cigna Priority Health	$303.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$200.79
Rate for Payer: Priority Health Narrow Network	$200.79
Rate for Payer: Priority Health SBD	$200.79
Rate for Payer: UMR Bronson Commercial	$199.64

PR BLUE TIDAL

Professional

Both

$60.00

Service Code	HCPCS 00072
Hospital Revenue Code	990
Min. Negotiated Rate	$24.00
Max. Negotiated Rate	$42.00
Rate for Payer: BCBS Complete	$24.00
Rate for Payer: Cash Price	$48.00
Rate for Payer: Priority Health Cigna Priority Health	$42.00
Rate for Payer: UMR Bronson Commercial	$27.60

PR BONE GRAFT ANY DONOR AREA MAJOR/LARGE

Professional

Both

$1,228.00

Service Code	HCPCS 20902
Min. Negotiated Rate	$175.09
Max. Negotiated Rate	$859.60
Rate for Payer: Aetna Commercial	$373.38
Rate for Payer: BCBS Complete	$183.84
Rate for Payer: BCBS Trust/PPO	$580.95
Rate for Payer: Cash Price	$982.40
Rate for Payer: Cash Price	$982.40
Rate for Payer: Meridian Medicaid	$183.84
Rate for Payer: Priority Health Choice Medicaid	$175.09
Rate for Payer: Priority Health Cigna Priority Health	$859.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$418.74
Rate for Payer: Priority Health Narrow Network	$418.74
Rate for Payer: Priority Health SBD	$418.74
Rate for Payer: UMR Bronson Commercial	$564.88

PR BONE GRAFT ANY DONOR AREA MINOR/SMALL

Professional

Both

$891.00

Service Code	HCPCS 20900
Min. Negotiated Rate	$114.81
Max. Negotiated Rate	$623.70
Rate for Payer: Aetna Commercial	$244.23
Rate for Payer: BCBS Complete	$120.55
Rate for Payer: BCBS Trust/PPO	$580.95
Rate for Payer: Cash Price	$712.80
Rate for Payer: Cash Price	$712.80
Rate for Payer: Meridian Medicaid	$120.55
Rate for Payer: Priority Health Choice Medicaid	$114.81
Rate for Payer: Priority Health Cigna Priority Health	$623.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$275.75
Rate for Payer: Priority Health Narrow Network	$275.75
Rate for Payer: Priority Health SBD	$275.75
Rate for Payer: UMR Bronson Commercial	$409.86

PR BONE GRF W/MVASC ANAST OTH/THN ILIAC CREST/METAR

Professional

Both

$4,498.00

Service Code	HCPCS 20962
Min. Negotiated Rate	$1,706.77
Max. Negotiated Rate	$4,061.20
Rate for Payer: Aetna Commercial	$3,549.97
Rate for Payer: BCBS Complete	$1,792.11
Rate for Payer: BCBS Trust/PPO	$3,247.68
Rate for Payer: Cash Price	$3,598.40
Rate for Payer: Cash Price	$3,598.40
Rate for Payer: Meridian Medicaid	$1,792.11
Rate for Payer: Priority Health Choice Medicaid	$1,706.77
Rate for Payer: Priority Health Cigna Priority Health	$3,148.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$4,061.20
Rate for Payer: Priority Health Narrow Network	$4,061.20
Rate for Payer: Priority Health SBD	$4,061.20
Rate for Payer: UMR Bronson Commercial	$2,069.08

PR BOTOX UNIT

Professional

Both

$13.00

Service Code	HCPCS 00084
Hospital Revenue Code	990
Min. Negotiated Rate	$5.20
Max. Negotiated Rate	$9.10
Rate for Payer: BCBS Complete	$5.20
Rate for Payer: Cash Price	$10.40
Rate for Payer: Priority Health Cigna Priority Health	$9.10
Rate for Payer: UMR Bronson Commercial	$5.98

PR BRACHIOPLASTY

Professional

Both

$4,500.00

Service Code	HCPCS 00537
Hospital Revenue Code	990
Min. Negotiated Rate	$1,800.00
Max. Negotiated Rate	$3,150.00
Rate for Payer: BCBS Complete	$1,800.00
Rate for Payer: Cash Price	$3,600.00
Rate for Payer: Priority Health Cigna Priority Health	$3,150.00
Rate for Payer: UMR Bronson Commercial	$2,070.00

Know your out-of-pocket cost for care.

All Charges