Bronson Methodist Hospital

All Charges

Charge

Type

Setting

Price

PR CLOSED TX RADIAL HEAD/NECK FX W/MANIPULATION

Professional

Both

$942.00

Service Code	HCPCS 24655
Min. Negotiated Rate	$269.66
Max. Negotiated Rate	$979.47
Rate for Payer: Aetna Commercial	$532.95
Rate for Payer: BCBS Complete	$283.14
Rate for Payer: BCBS Trust/PPO	$979.47
Rate for Payer: Cash Price	$753.60
Rate for Payer: Cash Price	$753.60
Rate for Payer: Meridian Medicaid	$283.14
Rate for Payer: Priority Health Choice Medicaid	$269.66
Rate for Payer: Priority Health Cigna Priority Health	$659.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$632.69
Rate for Payer: Priority Health Narrow Network	$632.69
Rate for Payer: Priority Health SBD	$632.69
Rate for Payer: UMR Bronson Commercial	$433.32

PR CLOSED TX RADIAL HEAD/NECK FX W/O MANIPULATION

Professional

Both

$632.00

Service Code	HCPCS 24650
Min. Negotiated Rate	$164.86
Max. Negotiated Rate	$1,113.13
Rate for Payer: Aetna Commercial	$323.50
Rate for Payer: BCBS Complete	$173.10
Rate for Payer: BCBS Trust/PPO	$1,113.13
Rate for Payer: Cash Price	$505.60
Rate for Payer: Cash Price	$505.60
Rate for Payer: Meridian Medicaid	$173.10
Rate for Payer: Priority Health Choice Medicaid	$164.86
Rate for Payer: Priority Health Cigna Priority Health	$442.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$387.07
Rate for Payer: Priority Health Narrow Network	$387.07
Rate for Payer: Priority Health SBD	$387.07
Rate for Payer: UMR Bronson Commercial	$290.72

PR CLOSED TX RADIAL SHAFT FRACTURE W/MANIPULATION

Professional

Both

$1,245.00

Service Code	HCPCS 25505
Min. Negotiated Rate	$305.23
Max. Negotiated Rate	$1,458.11
Rate for Payer: Aetna Commercial	$609.77
Rate for Payer: BCBS Complete	$320.49
Rate for Payer: BCBS Trust/PPO	$1,458.11
Rate for Payer: Cash Price	$996.00
Rate for Payer: Cash Price	$996.00
Rate for Payer: Meridian Medicaid	$320.49
Rate for Payer: Priority Health Choice Medicaid	$305.23
Rate for Payer: Priority Health Cigna Priority Health	$871.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$720.53
Rate for Payer: Priority Health Narrow Network	$720.53
Rate for Payer: Priority Health SBD	$720.53
Rate for Payer: UMR Bronson Commercial	$572.70

PR CLOSED TX RADIAL SHAFT FRACTURE W/O MANIPULATION

Professional

Both

$442.00

Service Code	HCPCS 25500
Min. Negotiated Rate	$172.74
Max. Negotiated Rate	$1,850.63
Rate for Payer: Aetna Commercial	$339.01
Rate for Payer: BCBS Complete	$181.38
Rate for Payer: BCBS Trust/PPO	$1,850.63
Rate for Payer: Cash Price	$353.60
Rate for Payer: Cash Price	$353.60
Rate for Payer: Meridian Medicaid	$181.38
Rate for Payer: Priority Health Choice Medicaid	$172.74
Rate for Payer: Priority Health Cigna Priority Health	$309.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$405.45
Rate for Payer: Priority Health Narrow Network	$405.45
Rate for Payer: Priority Health SBD	$405.45
Rate for Payer: UMR Bronson Commercial	$203.32

PR CLOSED TX RADIAL&ULNAR SHAFT FRACTURES W/MANJ

Professional

Both

$1,400.00

Service Code	HCPCS 25565
Min. Negotiated Rate	$306.93
Max. Negotiated Rate	$2,806.33
Rate for Payer: Aetna Commercial	$619.55
Rate for Payer: BCBS Complete	$322.28
Rate for Payer: BCBS Trust/PPO	$2,806.33
Rate for Payer: Cash Price	$1,120.00
Rate for Payer: Cash Price	$1,120.00
Rate for Payer: Meridian Medicaid	$322.28
Rate for Payer: Priority Health Choice Medicaid	$306.93
Rate for Payer: Priority Health Cigna Priority Health	$980.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$728.70
Rate for Payer: Priority Health Narrow Network	$728.70
Rate for Payer: Priority Health SBD	$728.70
Rate for Payer: UMR Bronson Commercial	$644.00

PR CLOSED TX RADIAL&ULNAR SHAFT FRACTURES W/O MAN

Professional

Both

$700.00

Service Code	HCPCS 25560
Min. Negotiated Rate	$173.60
Max. Negotiated Rate	$1,599.69
Rate for Payer: Aetna Commercial	$340.68
Rate for Payer: BCBS Complete	$182.28
Rate for Payer: BCBS Trust/PPO	$1,599.69
Rate for Payer: Cash Price	$560.00
Rate for Payer: Cash Price	$560.00
Rate for Payer: Meridian Medicaid	$182.28
Rate for Payer: Priority Health Choice Medicaid	$173.60
Rate for Payer: Priority Health Cigna Priority Health	$490.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$408.01
Rate for Payer: Priority Health Narrow Network	$408.01
Rate for Payer: Priority Health SBD	$408.01
Rate for Payer: UMR Bronson Commercial	$322.00

PR CLOSED TX SCAPULAR FRACTURE W/O MANIPULATION

Professional

Both

$602.00

Service Code	HCPCS 23570
Min. Negotiated Rate	$162.31
Max. Negotiated Rate	$553.66
Rate for Payer: Aetna Commercial	$319.45
Rate for Payer: BCBS Complete	$170.43
Rate for Payer: BCBS Trust/PPO	$553.66
Rate for Payer: Cash Price	$481.60
Rate for Payer: Cash Price	$481.60
Rate for Payer: Meridian Medicaid	$170.43
Rate for Payer: Priority Health Choice Medicaid	$162.31
Rate for Payer: Priority Health Cigna Priority Health	$421.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$380.95
Rate for Payer: Priority Health Narrow Network	$380.95
Rate for Payer: Priority Health SBD	$380.95
Rate for Payer: UMR Bronson Commercial	$276.92

PR CLOSED TX STERNOCLAVICULAR DISLC W/MANIPULATION

Professional

Both

$768.00

Service Code	HCPCS 23525
Min. Negotiated Rate	$241.33
Max. Negotiated Rate	$568.86
Rate for Payer: Aetna Commercial	$478.72
Rate for Payer: BCBS Complete	$253.40
Rate for Payer: BCBS Trust/PPO	$399.45
Rate for Payer: Cash Price	$614.40
Rate for Payer: Cash Price	$614.40
Rate for Payer: Meridian Medicaid	$253.40
Rate for Payer: Priority Health Choice Medicaid	$241.33
Rate for Payer: Priority Health Cigna Priority Health	$537.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$568.86
Rate for Payer: Priority Health Narrow Network	$568.86
Rate for Payer: Priority Health SBD	$568.86
Rate for Payer: UMR Bronson Commercial	$353.28

PR CLOSED TX TALOTARSAL JOINT DISLC W/O ANES

Professional

Both

$351.00

Service Code	HCPCS 28570
Min. Negotiated Rate	$131.42
Max. Negotiated Rate	$1,383.62
Rate for Payer: Aetna Commercial	$255.65
Rate for Payer: BCBS Complete	$137.99
Rate for Payer: BCBS Trust/PPO	$1,383.62
Rate for Payer: Cash Price	$280.80
Rate for Payer: Cash Price	$280.80
Rate for Payer: Meridian Medicaid	$137.99
Rate for Payer: Priority Health Choice Medicaid	$131.42
Rate for Payer: Priority Health Cigna Priority Health	$245.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$307.41
Rate for Payer: Priority Health Narrow Network	$307.41
Rate for Payer: Priority Health SBD	$307.41
Rate for Payer: UMR Bronson Commercial	$161.46

PR CLOSED TX TALOTARSAL JOINT DISLOCATION W/ANES

Professional

Both

$792.00

Service Code	HCPCS 28575
Min. Negotiated Rate	$224.50
Max. Negotiated Rate	$804.60
Rate for Payer: Aetna Commercial	$445.15
Rate for Payer: BCBS Complete	$235.72
Rate for Payer: BCBS Trust/PPO	$804.60
Rate for Payer: Cash Price	$633.60
Rate for Payer: Cash Price	$633.60
Rate for Payer: Meridian Medicaid	$235.72
Rate for Payer: Priority Health Choice Medicaid	$224.50
Rate for Payer: Priority Health Cigna Priority Health	$554.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$529.54
Rate for Payer: Priority Health Narrow Network	$529.54
Rate for Payer: Priority Health SBD	$529.54
Rate for Payer: UMR Bronson Commercial	$364.32

PR CLOSED TX TALUS FRACTURE W/MANIPULATION

Professional

Both

$792.00

Service Code	HCPCS 28435
Min. Negotiated Rate	$217.26
Max. Negotiated Rate	$1,149.05
Rate for Payer: Aetna Commercial	$390.08
Rate for Payer: BCBS Complete	$228.12
Rate for Payer: BCBS Trust/PPO	$1,149.05
Rate for Payer: Cash Price	$633.60
Rate for Payer: Cash Price	$633.60
Rate for Payer: Meridian Medicaid	$228.12
Rate for Payer: Priority Health Choice Medicaid	$217.26
Rate for Payer: Priority Health Cigna Priority Health	$554.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$512.18
Rate for Payer: Priority Health Narrow Network	$512.18
Rate for Payer: Priority Health SBD	$512.18
Rate for Payer: UMR Bronson Commercial	$364.32

PR CLOSED TX TALUS FRACTURE W/O MANIPULATION

Professional

Both

$660.00

Service Code	HCPCS 28430
Min. Negotiated Rate	$139.52
Max. Negotiated Rate	$540.45
Rate for Payer: Aetna Commercial	$277.32
Rate for Payer: BCBS Complete	$146.50
Rate for Payer: BCBS Trust/PPO	$540.45
Rate for Payer: Cash Price	$528.00
Rate for Payer: Cash Price	$528.00
Rate for Payer: Meridian Medicaid	$146.50
Rate for Payer: Priority Health Choice Medicaid	$139.52
Rate for Payer: Priority Health Cigna Priority Health	$462.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$328.34
Rate for Payer: Priority Health Narrow Network	$328.34
Rate for Payer: Priority Health SBD	$328.34
Rate for Payer: UMR Bronson Commercial	$303.60

PR CLOSED TX TARSOMETATARSAL DISLOCATION W/ANES

Professional

Both

$792.00

Service Code	HCPCS 28605
Min. Negotiated Rate	$202.35
Max. Negotiated Rate	$2,031.31
Rate for Payer: Aetna Commercial	$398.51
Rate for Payer: BCBS Complete	$212.47
Rate for Payer: BCBS Trust/PPO	$2,031.31
Rate for Payer: Cash Price	$633.60
Rate for Payer: Cash Price	$633.60
Rate for Payer: Meridian Medicaid	$212.47
Rate for Payer: Priority Health Choice Medicaid	$202.35
Rate for Payer: Priority Health Cigna Priority Health	$554.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$475.93
Rate for Payer: Priority Health Narrow Network	$475.93
Rate for Payer: Priority Health SBD	$475.93
Rate for Payer: UMR Bronson Commercial	$364.32

PR CLOSED TX TARSOMETATARSAL DISLOCATION W/O ANES

Professional

Both

$370.00

Service Code	HCPCS 28600
Min. Negotiated Rate	$105.44
Max. Negotiated Rate	$1,628.75
Rate for Payer: Aetna Commercial	$242.75
Rate for Payer: BCBS Complete	$110.71
Rate for Payer: BCBS Trust/PPO	$1,628.75
Rate for Payer: Cash Price	$296.00
Rate for Payer: Cash Price	$296.00
Rate for Payer: Meridian Medicaid	$110.71
Rate for Payer: Priority Health Choice Medicaid	$105.44
Rate for Payer: Priority Health Cigna Priority Health	$259.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$288.51
Rate for Payer: Priority Health Narrow Network	$288.51
Rate for Payer: Priority Health SBD	$288.51
Rate for Payer: UMR Bronson Commercial	$170.20

PR CLOSED TX TEMPOROMANDIBULAR DISLC COMP 1ST/SBSQ

Professional

Both

$1,067.00

Service Code	HCPCS 21485
Min. Negotiated Rate	$35.00
Max. Negotiated Rate	$1,218.41
Rate for Payer: Aetna Commercial	$1,032.91
Rate for Payer: BCBS Complete	$524.91
Rate for Payer: BCBS Trust/PPO	$35.00
Rate for Payer: Cash Price	$853.60
Rate for Payer: Cash Price	$853.60
Rate for Payer: Meridian Medicaid	$524.91
Rate for Payer: Priority Health Choice Medicaid	$499.91
Rate for Payer: Priority Health Cigna Priority Health	$746.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,218.41
Rate for Payer: Priority Health Narrow Network	$1,218.41
Rate for Payer: Priority Health SBD	$1,218.41
Rate for Payer: UMR Bronson Commercial	$490.82

PR CLOSED TX TEMPOROMANDIBULAR DISLOCATION 1ST/SBSQ

Professional

Both

$139.00

Service Code	HCPCS 21480
Min. Negotiated Rate	$19.81
Max. Negotiated Rate	$3,350.93
Rate for Payer: Aetna Commercial	$42.88
Rate for Payer: BCBS Complete	$20.80
Rate for Payer: BCBS Trust/PPO	$3,350.93
Rate for Payer: Cash Price	$111.20
Rate for Payer: Cash Price	$111.20
Rate for Payer: Meridian Medicaid	$20.80
Rate for Payer: Priority Health Choice Medicaid	$19.81
Rate for Payer: Priority Health Cigna Priority Health	$97.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$47.50
Rate for Payer: Priority Health Narrow Network	$47.50
Rate for Payer: Priority Health SBD	$47.50
Rate for Payer: UMR Bronson Commercial	$63.94

PR CLOSED TX ULNAR FRACTURE PROXIMAL END W/MANJ

Professional

Both

$1,230.00

Service Code	HCPCS 24675
Min. Negotiated Rate	$276.26
Max. Negotiated Rate	$1,365.66
Rate for Payer: Aetna Commercial	$553.15
Rate for Payer: BCBS Complete	$290.07
Rate for Payer: BCBS Trust/PPO	$1,365.66
Rate for Payer: Cash Price	$984.00
Rate for Payer: Cash Price	$984.00
Rate for Payer: Meridian Medicaid	$290.07
Rate for Payer: Priority Health Choice Medicaid	$276.26
Rate for Payer: Priority Health Cigna Priority Health	$861.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$652.61
Rate for Payer: Priority Health Narrow Network	$652.61
Rate for Payer: Priority Health SBD	$652.61
Rate for Payer: UMR Bronson Commercial	$565.80

PR CLOSED TX ULNAR FRACTURE PROXIMAL END W/O MANJ

Professional

Both

$781.00

Service Code	HCPCS 24670
Min. Negotiated Rate	$178.92
Max. Negotiated Rate	$1,283.24
Rate for Payer: Aetna Commercial	$353.21
Rate for Payer: BCBS Complete	$187.87
Rate for Payer: BCBS Trust/PPO	$1,283.24
Rate for Payer: Cash Price	$624.80
Rate for Payer: Cash Price	$624.80
Rate for Payer: Meridian Medicaid	$187.87
Rate for Payer: Priority Health Choice Medicaid	$178.92
Rate for Payer: Priority Health Cigna Priority Health	$546.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$421.80
Rate for Payer: Priority Health Narrow Network	$421.80
Rate for Payer: Priority Health SBD	$421.80
Rate for Payer: UMR Bronson Commercial	$359.26

PR CLOSED TX ULNAR SHAFT FRACTURE W/MANIPULATION

Professional

Both

$1,167.00

Service Code	HCPCS 25535
Min. Negotiated Rate	$302.46
Max. Negotiated Rate	$1,028.60
Rate for Payer: Aetna Commercial	$608.96
Rate for Payer: BCBS Complete	$317.58
Rate for Payer: BCBS Trust/PPO	$1,028.60
Rate for Payer: Cash Price	$933.60
Rate for Payer: Cash Price	$933.60
Rate for Payer: Meridian Medicaid	$317.58
Rate for Payer: Priority Health Choice Medicaid	$302.46
Rate for Payer: Priority Health Cigna Priority Health	$816.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$714.40
Rate for Payer: Priority Health Narrow Network	$714.40
Rate for Payer: Priority Health SBD	$714.40
Rate for Payer: UMR Bronson Commercial	$536.82

PR CLOSED TX ULNAR SHAFT FRACTURE W/O MANIPULATION

Professional

Both

$642.00

Service Code	HCPCS 25530
Min. Negotiated Rate	$162.95
Max. Negotiated Rate	$1,133.73
Rate for Payer: Aetna Commercial	$319.74
Rate for Payer: BCBS Complete	$171.10
Rate for Payer: BCBS Trust/PPO	$1,133.73
Rate for Payer: Cash Price	$513.60
Rate for Payer: Cash Price	$513.60
Rate for Payer: Meridian Medicaid	$171.10
Rate for Payer: Priority Health Choice Medicaid	$162.95
Rate for Payer: Priority Health Cigna Priority Health	$449.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$382.48
Rate for Payer: Priority Health Narrow Network	$382.48
Rate for Payer: Priority Health SBD	$382.48
Rate for Payer: UMR Bronson Commercial	$295.32

PR CLOSE MEDIAN STERNOTOMY SEP W/WO DEBRIDEMENT SPX

Professional

Both

$2,053.00

Service Code	HCPCS 21750
Min. Negotiated Rate	$430.05
Max. Negotiated Rate	$1,437.10
Rate for Payer: Aetna Commercial	$910.89
Rate for Payer: BCBS Complete	$451.55
Rate for Payer: BCBS Trust/PPO	$1,388.14
Rate for Payer: Cash Price	$1,642.40
Rate for Payer: Cash Price	$1,642.40
Rate for Payer: Meridian Medicaid	$451.55
Rate for Payer: Priority Health Choice Medicaid	$430.05
Rate for Payer: Priority Health Cigna Priority Health	$1,437.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,025.89
Rate for Payer: Priority Health Narrow Network	$1,025.89
Rate for Payer: Priority Health SBD	$1,025.89
Rate for Payer: UMR Bronson Commercial	$944.38

PR CLOSURE CYSTOSTOMY SEPARATE PROCEDURE

Professional

Both

$1,392.00

Service Code	HCPCS 51880
Min. Negotiated Rate	$298.20
Max. Negotiated Rate	$1,691.09
Rate for Payer: Aetna Commercial	$598.61
Rate for Payer: BCBS Complete	$313.11
Rate for Payer: BCBS Trust/PPO	$1,691.09
Rate for Payer: Cash Price	$1,113.60
Rate for Payer: Cash Price	$1,113.60
Rate for Payer: Meridian Medicaid	$313.11
Rate for Payer: Priority Health Choice Medicaid	$298.20
Rate for Payer: Priority Health Cigna Priority Health	$974.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$742.99
Rate for Payer: Priority Health Narrow Network	$742.99
Rate for Payer: Priority Health SBD	$742.99
Rate for Payer: UMR Bronson Commercial	$640.32

PR CLOSURE ENTEROSTOMY LG/SMALL INTESTINE

Professional

Both

$2,217.00

Service Code	HCPCS 44620
Min. Negotiated Rate	$210.79
Max. Negotiated Rate	$1,551.90
Rate for Payer: Aetna Commercial	$1,162.18
Rate for Payer: BCBS Complete	$578.36
Rate for Payer: BCBS Trust/PPO	$210.79
Rate for Payer: Cash Price	$1,773.60
Rate for Payer: Cash Price	$1,773.60
Rate for Payer: Meridian Medicaid	$578.36
Rate for Payer: Priority Health Choice Medicaid	$550.82
Rate for Payer: Priority Health Cigna Priority Health	$1,551.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,514.61
Rate for Payer: Priority Health Narrow Network	$1,514.61
Rate for Payer: Priority Health SBD	$1,514.61
Rate for Payer: UMR Bronson Commercial	$1,019.82

PR CLOSURE GASTROCOLIC FISTULA

Professional

Both

$3,817.00

Service Code	HCPCS 43880
Min. Negotiated Rate	$198.11
Max. Negotiated Rate	$2,781.10
Rate for Payer: Aetna Commercial	$2,144.57
Rate for Payer: BCBS Complete	$1,077.32
Rate for Payer: BCBS Trust/PPO	$198.11
Rate for Payer: Cash Price	$3,053.60
Rate for Payer: Cash Price	$3,053.60
Rate for Payer: Meridian Medicaid	$1,077.32
Rate for Payer: Priority Health Choice Medicaid	$1,026.02
Rate for Payer: Priority Health Cigna Priority Health	$2,671.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,781.10
Rate for Payer: Priority Health Narrow Network	$2,781.10
Rate for Payer: Priority Health SBD	$2,781.10
Rate for Payer: UMR Bronson Commercial	$1,755.82

PR CLOSURE GASTROSTOMY SURG

Professional

Both

$1,917.00

Service Code	HCPCS 43870
Min. Negotiated Rate	$202.87
Max. Negotiated Rate	$1,341.90
Rate for Payer: Aetna Commercial	$958.29
Rate for Payer: BCBS Complete	$477.27
Rate for Payer: BCBS Trust/PPO	$202.87
Rate for Payer: Cash Price	$1,533.60
Rate for Payer: Cash Price	$1,533.60
Rate for Payer: Meridian Medicaid	$477.27
Rate for Payer: Priority Health Choice Medicaid	$454.54
Rate for Payer: Priority Health Cigna Priority Health	$1,341.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,250.03
Rate for Payer: Priority Health Narrow Network	$1,250.03
Rate for Payer: Priority Health SBD	$1,250.03
Rate for Payer: UMR Bronson Commercial	$881.82

Know your out-of-pocket cost for care.

All Charges