Bronson Methodist Hospital

All Charges

Charge

Type

Setting

Price

PR CYSTO W/DESTRUCTION OF LESIONS

Professional

Both

$2,770.00

Service Code	HCPCS 52214
Min. Negotiated Rate	$109.70
Max. Negotiated Rate	$2,177.12
Rate for Payer: Aetna Commercial	$227.00
Rate for Payer: BCBS Complete	$115.18
Rate for Payer: BCBS Trust/PPO	$2,177.12
Rate for Payer: Cash Price	$2,216.00
Rate for Payer: Cash Price	$2,216.00
Rate for Payer: Meridian Medicaid	$115.18
Rate for Payer: Priority Health Choice Medicaid	$109.70
Rate for Payer: Priority Health Cigna Priority Health	$1,939.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$276.66
Rate for Payer: Priority Health Narrow Network	$276.66
Rate for Payer: Priority Health SBD	$276.66
Rate for Payer: UMR Bronson Commercial	$1,274.20

PR CYSTO W/INSERT URETERAL STENT

Professional

Both

$850.00

Service Code	HCPCS 52332
Min. Negotiated Rate	$97.98
Max. Negotiated Rate	$2,268.52
Rate for Payer: Aetna Commercial	$198.36
Rate for Payer: BCBS Complete	$102.88
Rate for Payer: BCBS Trust/PPO	$2,268.52
Rate for Payer: Cash Price	$680.00
Rate for Payer: Cash Price	$680.00
Rate for Payer: Meridian Medicaid	$102.88
Rate for Payer: Priority Health Choice Medicaid	$97.98
Rate for Payer: Priority Health Cigna Priority Health	$595.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$245.87
Rate for Payer: Priority Health Narrow Network	$245.87
Rate for Payer: Priority Health SBD	$245.87
Rate for Payer: UMR Bronson Commercial	$391.00

PR CYSTO W/IRRIG & EVAC MULTPLE OBSTRUCTING CLOTS

Professional

Both

$755.00

Service Code	HCPCS 52001
Min. Negotiated Rate	$180.41
Max. Negotiated Rate	$1,930.41
Rate for Payer: Aetna Commercial	$367.75
Rate for Payer: BCBS Complete	$189.43
Rate for Payer: BCBS Trust/PPO	$1,930.41
Rate for Payer: Cash Price	$604.00
Rate for Payer: Cash Price	$604.00
Rate for Payer: Meridian Medicaid	$189.43
Rate for Payer: Priority Health Choice Medicaid	$180.41
Rate for Payer: Priority Health Cigna Priority Health	$528.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$452.81
Rate for Payer: Priority Health Narrow Network	$452.81
Rate for Payer: Priority Health SBD	$452.81
Rate for Payer: UMR Bronson Commercial	$347.30

PR CYSTO W/REMOVAL OF LESIONS MINOR

Professional

Both

$2,280.00

Service Code	HCPCS 52224
Min. Negotiated Rate	$126.95
Max. Negotiated Rate	$2,846.48
Rate for Payer: Aetna Commercial	$261.58
Rate for Payer: BCBS Complete	$133.30
Rate for Payer: BCBS Trust/PPO	$2,846.48
Rate for Payer: Cash Price	$1,824.00
Rate for Payer: Cash Price	$1,824.00
Rate for Payer: Meridian Medicaid	$133.30
Rate for Payer: Priority Health Choice Medicaid	$126.95
Rate for Payer: Priority Health Cigna Priority Health	$1,596.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$320.43
Rate for Payer: Priority Health Narrow Network	$320.43
Rate for Payer: Priority Health SBD	$320.43
Rate for Payer: UMR Bronson Commercial	$1,048.80

PR CYSTO W/REMOVAL OF TUMORS SMALL

Professional

Both

$1,056.00

Service Code	HCPCS 52234
Min. Negotiated Rate	$154.43
Max. Negotiated Rate	$5,244.96
Rate for Payer: Aetna Commercial	$314.10
Rate for Payer: BCBS Complete	$162.15
Rate for Payer: BCBS Trust/PPO	$5,244.96
Rate for Payer: Cash Price	$844.80
Rate for Payer: Cash Price	$844.80
Rate for Payer: Meridian Medicaid	$162.15
Rate for Payer: Priority Health Choice Medicaid	$154.43
Rate for Payer: Priority Health Cigna Priority Health	$739.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$387.98
Rate for Payer: Priority Health Narrow Network	$387.98
Rate for Payer: Priority Health SBD	$387.98
Rate for Payer: UMR Bronson Commercial	$485.76

PR CYSTO W/RESCJ/FULG ORTHOPIC URETEROCELE UNI/BI

Professional

Both

$539.00

Service Code	HCPCS 52300
Min. Negotiated Rate	$175.73
Max. Negotiated Rate	$1,512.52
Rate for Payer: Aetna Commercial	$358.89
Rate for Payer: BCBS Complete	$184.52
Rate for Payer: BCBS Trust/PPO	$1,512.52
Rate for Payer: Cash Price	$431.20
Rate for Payer: Cash Price	$431.20
Rate for Payer: Meridian Medicaid	$184.52
Rate for Payer: Priority Health Choice Medicaid	$175.73
Rate for Payer: Priority Health Cigna Priority Health	$377.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$442.56
Rate for Payer: Priority Health Narrow Network	$442.56
Rate for Payer: Priority Health SBD	$442.56
Rate for Payer: UMR Bronson Commercial	$247.94

PR CYSTO W/RESECJ ECTOPIC URETEROCELE UNI/BI

Professional

Both

$571.22

Service Code	HCPCS 52301
Min. Negotiated Rate	$182.12
Max. Negotiated Rate	$1,202.94
Rate for Payer: Aetna Commercial	$371.30
Rate for Payer: BCBS Complete	$191.23
Rate for Payer: BCBS Trust/PPO	$1,202.94
Rate for Payer: Cash Price	$456.98
Rate for Payer: Cash Price	$456.98
Rate for Payer: Meridian Medicaid	$191.23
Rate for Payer: Priority Health Choice Medicaid	$182.12
Rate for Payer: Priority Health Cigna Priority Health	$399.85
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$457.15
Rate for Payer: Priority Health Narrow Network	$457.15
Rate for Payer: Priority Health SBD	$457.15
Rate for Payer: UMR Bronson Commercial	$262.76

PR CYSTO W/SIMPLE REMOVAL STONE & STENT

Professional

Both

$578.00

Service Code	HCPCS 52310
Min. Negotiated Rate	$95.42
Max. Negotiated Rate	$904.45
Rate for Payer: Aetna Commercial	$193.36
Rate for Payer: BCBS Complete	$100.19
Rate for Payer: BCBS Trust/PPO	$904.45
Rate for Payer: Cash Price	$462.40
Rate for Payer: Cash Price	$462.40
Rate for Payer: Meridian Medicaid	$100.19
Rate for Payer: Priority Health Choice Medicaid	$95.42
Rate for Payer: Priority Health Cigna Priority Health	$404.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$239.38
Rate for Payer: Priority Health Narrow Network	$239.38
Rate for Payer: Priority Health SBD	$239.38
Rate for Payer: UMR Bronson Commercial	$265.88

PR CYSTO W/SUBURTRIC NJX IMPLT MATRL

Professional

Both

$1,287.00

Service Code	HCPCS 52327
Min. Negotiated Rate	$162.31
Max. Negotiated Rate	$2,129.58
Rate for Payer: Aetna Commercial	$338.60
Rate for Payer: BCBS Complete	$170.43
Rate for Payer: BCBS Trust/PPO	$2,129.58
Rate for Payer: Cash Price	$1,029.60
Rate for Payer: Cash Price	$1,029.60
Rate for Payer: Meridian Medicaid	$170.43
Rate for Payer: Priority Health Choice Medicaid	$162.31
Rate for Payer: Priority Health Cigna Priority Health	$900.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$408.51
Rate for Payer: Priority Health Narrow Network	$408.51
Rate for Payer: Priority Health SBD	$408.51
Rate for Payer: UMR Bronson Commercial	$592.02

PR CYSTO W/TX INTRA-RENAL STRICTURE

Professional

Both

$664.00

Service Code	HCPCS 52343
Min. Negotiated Rate	$215.77
Max. Negotiated Rate	$2,659.46
Rate for Payer: Aetna Commercial	$439.49
Rate for Payer: BCBS Complete	$226.56
Rate for Payer: BCBS Trust/PPO	$2,659.46
Rate for Payer: Cash Price	$531.20
Rate for Payer: Cash Price	$531.20
Rate for Payer: Meridian Medicaid	$226.56
Rate for Payer: Priority Health Choice Medicaid	$215.77
Rate for Payer: Priority Health Cigna Priority Health	$464.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$542.52
Rate for Payer: Priority Health Narrow Network	$542.52
Rate for Payer: Priority Health SBD	$542.52
Rate for Payer: UMR Bronson Commercial	$305.44

PR CYSTO W/TX URETERAL STRICTURE

Professional

Both

$1,507.00

Service Code	HCPCS 52341
Min. Negotiated Rate	$178.49
Max. Negotiated Rate	$2,160.75
Rate for Payer: Aetna Commercial	$363.22
Rate for Payer: BCBS Complete	$187.41
Rate for Payer: BCBS Trust/PPO	$2,160.75
Rate for Payer: Cash Price	$1,205.60
Rate for Payer: Cash Price	$1,205.60
Rate for Payer: Meridian Medicaid	$187.41
Rate for Payer: Priority Health Choice Medicaid	$178.49
Rate for Payer: Priority Health Cigna Priority Health	$1,054.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$448.49
Rate for Payer: Priority Health Narrow Network	$448.49
Rate for Payer: Priority Health SBD	$448.49
Rate for Payer: UMR Bronson Commercial	$693.22

PR CYSTO W/TX URETEROPELVIC JUNCTION STRICTURE

Professional

Both

$1,678.00

Service Code	HCPCS 52342
Min. Negotiated Rate	$194.26
Max. Negotiated Rate	$1,174.60
Rate for Payer: Aetna Commercial	$395.15
Rate for Payer: BCBS Complete	$203.97
Rate for Payer: BCBS Trust/PPO	$440.60
Rate for Payer: Cash Price	$1,342.40
Rate for Payer: Cash Price	$1,342.40
Rate for Payer: Meridian Medicaid	$203.97
Rate for Payer: Priority Health Choice Medicaid	$194.26
Rate for Payer: Priority Health Cigna Priority Health	$1,174.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$486.86
Rate for Payer: Priority Health Narrow Network	$486.86
Rate for Payer: Priority Health SBD	$486.86
Rate for Payer: UMR Bronson Commercial	$771.88

PR CYSTO W/URETEROSCOPY W/LITHOTRIPSY

Professional

Both

$808.00

Service Code	HCPCS 52353
Min. Negotiated Rate	$245.80
Max. Negotiated Rate	$7,607.52
Rate for Payer: Aetna Commercial	$501.54
Rate for Payer: BCBS Complete	$258.09
Rate for Payer: BCBS Trust/PPO	$7,607.52
Rate for Payer: Cash Price	$646.40
Rate for Payer: Cash Price	$646.40
Rate for Payer: Meridian Medicaid	$258.09
Rate for Payer: Priority Health Choice Medicaid	$245.80
Rate for Payer: Priority Health Cigna Priority Health	$565.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$617.63
Rate for Payer: Priority Health Narrow Network	$617.63
Rate for Payer: Priority Health SBD	$617.63
Rate for Payer: UMR Bronson Commercial	$371.68

PR CYSTO W/URETEROSCOPY W/RMVL/MANJ STONES

Professional

Both

$2,941.00

Service Code	HCPCS 52352
Min. Negotiated Rate	$222.16
Max. Negotiated Rate	$2,058.70
Rate for Payer: Aetna Commercial	$452.78
Rate for Payer: BCBS Complete	$233.27
Rate for Payer: BCBS Trust/PPO	$677.97
Rate for Payer: Cash Price	$2,352.80
Rate for Payer: Cash Price	$2,352.80
Rate for Payer: Meridian Medicaid	$233.27
Rate for Payer: Priority Health Choice Medicaid	$222.16
Rate for Payer: Priority Health Cigna Priority Health	$2,058.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$558.18
Rate for Payer: Priority Health Narrow Network	$558.18
Rate for Payer: Priority Health SBD	$558.18
Rate for Payer: UMR Bronson Commercial	$1,352.86

PR CYSTO W/URTROSCOPY&/PYELOSCOPY DX

Professional

Both

$596.00

Service Code	HCPCS 52351
Min. Negotiated Rate	$190.21
Max. Negotiated Rate	$476.60
Rate for Payer: Aetna Commercial	$386.83
Rate for Payer: BCBS Complete	$199.72
Rate for Payer: BCBS Trust/PPO	$393.43
Rate for Payer: Cash Price	$476.80
Rate for Payer: Cash Price	$476.80
Rate for Payer: Meridian Medicaid	$199.72
Rate for Payer: Priority Health Choice Medicaid	$190.21
Rate for Payer: Priority Health Cigna Priority Health	$417.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$476.60
Rate for Payer: Priority Health Narrow Network	$476.60
Rate for Payer: Priority Health SBD	$476.60
Rate for Payer: UMR Bronson Commercial	$274.16

PR CYSTO W/URTROSCOPY W/TX INTRA-RENAL STRICTURE

Professional

Both

$867.00

Service Code	HCPCS 52346
Min. Negotiated Rate	$279.88
Max. Negotiated Rate	$2,753.98
Rate for Payer: Aetna Commercial	$571.60
Rate for Payer: BCBS Complete	$293.87
Rate for Payer: BCBS Trust/PPO	$2,753.98
Rate for Payer: Cash Price	$693.60
Rate for Payer: Cash Price	$693.60
Rate for Payer: Meridian Medicaid	$293.87
Rate for Payer: Priority Health Choice Medicaid	$279.88
Rate for Payer: Priority Health Cigna Priority Health	$606.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$702.46
Rate for Payer: Priority Health Narrow Network	$702.46
Rate for Payer: Priority Health SBD	$702.46
Rate for Payer: UMR Bronson Commercial	$398.82

PR CYSTO W/URTROSCOPY W/TX URETERAL STRICTURE

Professional

Both

$783.00

Service Code	HCPCS 52344
Min. Negotiated Rate	$231.96
Max. Negotiated Rate	$3,736.67
Rate for Payer: Aetna Commercial	$471.86
Rate for Payer: BCBS Complete	$243.56
Rate for Payer: BCBS Trust/PPO	$3,736.67
Rate for Payer: Cash Price	$626.40
Rate for Payer: Cash Price	$626.40
Rate for Payer: Meridian Medicaid	$243.56
Rate for Payer: Priority Health Choice Medicaid	$231.96
Rate for Payer: Priority Health Cigna Priority Health	$548.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$580.89
Rate for Payer: Priority Health Narrow Network	$580.89
Rate for Payer: Priority Health SBD	$580.89
Rate for Payer: UMR Bronson Commercial	$360.18

PR CYSTO W/URTROSCOPY W/TX URTROPEL JUNCT STRIX

Professional

Both

$1,105.00

Service Code	HCPCS 52345
Min. Negotiated Rate	$247.51
Max. Negotiated Rate	$3,934.25
Rate for Payer: Aetna Commercial	$504.64
Rate for Payer: BCBS Complete	$259.89
Rate for Payer: BCBS Trust/PPO	$3,934.25
Rate for Payer: Cash Price	$884.00
Rate for Payer: Cash Price	$884.00
Rate for Payer: Meridian Medicaid	$259.89
Rate for Payer: Priority Health Choice Medicaid	$247.51
Rate for Payer: Priority Health Cigna Priority Health	$773.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$620.86
Rate for Payer: Priority Health Narrow Network	$620.86
Rate for Payer: Priority Health SBD	$620.86
Rate for Payer: UMR Bronson Commercial	$508.30

PR DACRYOCSTORHINOSTOMY

Professional

Both

$1,541.00

Service Code	HCPCS 68720
Min. Negotiated Rate	$245.66
Max. Negotiated Rate	$1,405.01
Rate for Payer: Aetna Commercial	$1,040.24
Rate for Payer: BCBS Complete	$539.89
Rate for Payer: BCBS Trust/PPO	$245.66
Rate for Payer: Cash Price	$1,232.80
Rate for Payer: Cash Price	$1,232.80
Rate for Payer: Meridian Medicaid	$539.89
Rate for Payer: Priority Health Choice Medicaid	$514.18
Rate for Payer: Priority Health Cigna Priority Health	$1,078.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,405.01
Rate for Payer: Priority Health Narrow Network	$1,405.01
Rate for Payer: Priority Health SBD	$1,405.01
Rate for Payer: UMR Bronson Commercial	$708.86

PR DAILY HOSP MGMT EDRL/SARACH CONT DRUG ADMN

Professional

Both

$3.00

Service Code	HCPCS 01996
Min. Negotiated Rate	$1.20
Max. Negotiated Rate	$133.50
Rate for Payer: BCBS Complete	$1.20
Rate for Payer: Cash Price	$2.40
Rate for Payer: Cash Price	$2.40
Rate for Payer: Priority Health Cigna Priority Health	$2.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$133.50
Rate for Payer: Priority Health Narrow Network	$133.50
Rate for Payer: Priority Health SBD	$133.50
Rate for Payer: UMR Bronson Commercial	$1.38

PR DBRDMT EXTENSV ECZEMA/INFECT SKN UP 10% BDY SURF

Professional

Both

$88.00

Service Code	HCPCS 11000
Min. Negotiated Rate	$11.15
Max. Negotiated Rate	$61.60
Rate for Payer: Aetna Commercial	$30.50
Rate for Payer: BCBS Complete	$18.34
Rate for Payer: BCBS Trust/PPO	$11.15
Rate for Payer: Cash Price	$70.40
Rate for Payer: Cash Price	$70.40
Rate for Payer: Meridian Medicaid	$18.34
Rate for Payer: Priority Health Choice Medicaid	$17.47
Rate for Payer: Priority Health Cigna Priority Health	$61.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$32.88
Rate for Payer: Priority Health Narrow Network	$32.88
Rate for Payer: Priority Health SBD	$32.88
Rate for Payer: UMR Bronson Commercial	$40.48

PR DBRDMT EXTNSVE ECZEMA/INFECT SKN EA 10% BDY SURF

Professional

Both

$47.00

Service Code	HCPCS 11001
Min. Negotiated Rate	$9.37
Max. Negotiated Rate	$2,904.75
Rate for Payer: Aetna Commercial	$15.82
Rate for Payer: BCBS Complete	$9.84
Rate for Payer: BCBS Trust/PPO	$2,904.75
Rate for Payer: Cash Price	$37.60
Rate for Payer: Cash Price	$37.60
Rate for Payer: Meridian Medicaid	$9.84
Rate for Payer: Priority Health Choice Medicaid	$9.37
Rate for Payer: Priority Health Cigna Priority Health	$32.90
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	$21.62

PR DBRDMT FX&/DISLC SUBQ T/M/F BONE

Professional

Both

$1,194.00

Service Code	HCPCS 11012
Min. Negotiated Rate	$25.40
Max. Negotiated Rate	$835.80
Rate for Payer: Aetna Commercial	$453.05
Rate for Payer: BCBS Complete	$277.33
Rate for Payer: BCBS Trust/PPO	$25.40
Rate for Payer: Cash Price	$955.20
Rate for Payer: Cash Price	$955.20
Rate for Payer: Meridian Medicaid	$277.33
Rate for Payer: Priority Health Choice Medicaid	$264.12
Rate for Payer: Priority Health Cigna Priority Health	$835.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$507.64
Rate for Payer: Priority Health Narrow Network	$507.64
Rate for Payer: Priority Health SBD	$507.64
Rate for Payer: UMR Bronson Commercial	$549.24

PR DBRDMT SKN SUBQ T/M/F NECRO INFCTJ ABDL WALL

Professional

Both

$1,395.00

Service Code	HCPCS 11005
Hospital Charge Code	11005
Min. Negotiated Rate	$488.84
Max. Negotiated Rate	$2,189.70
Rate for Payer: Aetna Commercial	$855.76
Rate for Payer: BCBS Complete	$513.28
Rate for Payer: BCBS Trust/PPO	$2,189.70
Rate for Payer: Cash Price	$1,116.00
Rate for Payer: Cash Price	$1,116.00
Rate for Payer: Meridian Medicaid	$513.28
Rate for Payer: Priority Health Choice Medicaid	$488.84
Rate for Payer: Priority Health Cigna Priority Health	$976.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$940.87
Rate for Payer: Priority Health Narrow Network	$940.87
Rate for Payer: Priority Health SBD	$940.87
Rate for Payer: UMR Bronson Commercial	$641.70

PR DBRDMT SKN SUBQ T/M/F NECRO INFCTJ ABDL WALL

Facility

$1,395.00

Service Code	CPT 11005
Hospital Charge Code	11005
Min. Negotiated Rate	$516.15
Max. Negotiated Rate	$2,730.99
Rate for Payer: Aetna American Axle	$906.75
Rate for Payer: Aetna Commercial	$1,185.75
Rate for Payer: Aetna New Business (MI Preferred)	$906.75
Rate for Payer: BCBS Complete	$558.00
Rate for Payer: BCBS Trust/PPO	$2,730.99
Rate for Payer: Cash Price	$1,116.00
Rate for Payer: Cash Price	$1,116.00
Rate for Payer: Cofinity Commercial	$1,199.70
Rate for Payer: Cofinity Commercial	$976.50
Rate for Payer: Encore Health Key Benefits Commercial	$1,116.00
Rate for Payer: Healthscope Commercial	$1,255.50
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial	$976.50
Rate for Payer: Lakeland Regional Health Systems Commercial	$1,046.25
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1,185.75
Rate for Payer: PHP Commercial	$1,185.75
Rate for Payer: Priority Health Cigna Priority Health	$976.50
Rate for Payer: Priority Health SBD	$878.85
Rate for Payer: UHC All Payor (Choice/PPO)	$826.63
Rate for Payer: UHC Exchange	$751.48
Rate for Payer: UMR Bronson Commercial	$516.15
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$1,046.25

Know your out-of-pocket cost for care.

All Charges