Bronson Methodist Hospital

All Charges

Charge

Type

Setting

Price

PR DERMAL FILLER RESTYLANE 1 UNIT

Professional

Both

$650.00

Service Code	HCPCS 00253
Hospital Revenue Code	990
Min. Negotiated Rate	$260.00
Max. Negotiated Rate	$455.00
Rate for Payer: BCBS Complete	$260.00
Rate for Payer: Cash Price	$520.00
Rate for Payer: Priority Health Cigna Priority Health	$455.00
Rate for Payer: UMR Bronson Commercial	$299.00

PR DERMAL FILLER RESTYLANE DEFYNE

Professional

Both

$700.00

Service Code	HCPCS 00360
Hospital Revenue Code	990
Min. Negotiated Rate	$280.00
Max. Negotiated Rate	$490.00
Rate for Payer: BCBS Complete	$280.00
Rate for Payer: Cash Price	$560.00
Rate for Payer: Priority Health Cigna Priority Health	$490.00
Rate for Payer: UMR Bronson Commercial	$322.00

PR DERMAL FILLER RESTYLANE LYFT

Professional

Both

$650.00

Service Code	HCPCS 00359
Hospital Revenue Code	990
Min. Negotiated Rate	$260.00
Max. Negotiated Rate	$455.00
Rate for Payer: BCBS Complete	$260.00
Rate for Payer: Cash Price	$520.00
Rate for Payer: Priority Health Cigna Priority Health	$455.00
Rate for Payer: UMR Bronson Commercial	$299.00

PR DERMAL FILLER RESTYLANE REFYNE

Professional

Both

$700.00

Service Code	HCPCS 00361
Hospital Revenue Code	990
Min. Negotiated Rate	$280.00
Max. Negotiated Rate	$490.00
Rate for Payer: BCBS Complete	$280.00
Rate for Payer: Cash Price	$560.00
Rate for Payer: Priority Health Cigna Priority Health	$490.00
Rate for Payer: UMR Bronson Commercial	$322.00

PR DERMAL FILLER VOLBELLA

Professional

Both

$400.00

Service Code	HCPCS 00092
Hospital Revenue Code	990
Min. Negotiated Rate	$160.00
Max. Negotiated Rate	$280.00
Rate for Payer: BCBS Complete	$160.00
Rate for Payer: Cash Price	$320.00
Rate for Payer: Priority Health Cigna Priority Health	$280.00
Rate for Payer: UMR Bronson Commercial	$184.00

PR DERMAL FILLER VOLBELLA >1

Professional

Both

$700.00

Service Code	HCPCS 00120
Hospital Revenue Code	990
Min. Negotiated Rate	$280.00
Max. Negotiated Rate	$490.00
Rate for Payer: BCBS Complete	$280.00
Rate for Payer: Cash Price	$560.00
Rate for Payer: Priority Health Cigna Priority Health	$490.00
Rate for Payer: UMR Bronson Commercial	$322.00

PR DESTROY NERVE,CERV SPINAL MUSCLES

Professional

Both

$354.00

Service Code	HCPCS 64613
Min. Negotiated Rate	$141.60
Max. Negotiated Rate	$247.80
Rate for Payer: BCBS Complete	$141.60
Rate for Payer: Cash Price	$283.20
Rate for Payer: Priority Health Cigna Priority Health	$247.80
Rate for Payer: UMR Bronson Commercial	$162.84

PR DESTRUCTION BENIGN LESIONS 15/>

Professional

Both

$213.00

Service Code	HCPCS 17111
Min. Negotiated Rate	$53.46
Max. Negotiated Rate	$562.50
Rate for Payer: Aetna Commercial	$85.72
Rate for Payer: BCBS Complete	$56.13
Rate for Payer: BCBS Trust/PPO	$562.50
Rate for Payer: Cash Price	$170.40
Rate for Payer: Cash Price	$170.40
Rate for Payer: Meridian Medicaid	$56.13
Rate for Payer: Priority Health Choice Medicaid	$53.46
Rate for Payer: Priority Health Cigna Priority Health	$149.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$100.70
Rate for Payer: Priority Health Narrow Network	$100.70
Rate for Payer: Priority Health SBD	$100.70
Rate for Payer: UMR Bronson Commercial	$97.98

PR DESTRUCTION BENIGN LESIONS UP TO 14

Professional

Both

$179.00

Service Code	HCPCS 17110
Hospital Charge Code	17110
Min. Negotiated Rate	$44.09
Max. Negotiated Rate	$4,160.00
Rate for Payer: Aetna Commercial	$69.33
Rate for Payer: BCBS Complete	$46.29
Rate for Payer: BCBS Trust/PPO	$4,160.00
Rate for Payer: Cash Price	$143.20
Rate for Payer: Cash Price	$143.20
Rate for Payer: Meridian Medicaid	$46.29
Rate for Payer: Priority Health Choice Medicaid	$44.09
Rate for Payer: Priority Health Cigna Priority Health	$125.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$82.20
Rate for Payer: Priority Health Narrow Network	$82.20
Rate for Payer: Priority Health SBD	$82.20
Rate for Payer: UMR Bronson Commercial	$82.34

PR DESTRUCTION BENIGN LESIONS UP TO 14

Professional

Both

$179.00

Service Code	HCPCS 17110
Min. Negotiated Rate	$44.09
Max. Negotiated Rate	$4,160.00
Rate for Payer: Aetna Commercial	$69.33
Rate for Payer: BCBS Complete	$46.29
Rate for Payer: BCBS Trust/PPO	$4,160.00
Rate for Payer: Cash Price	$143.20
Rate for Payer: Cash Price	$143.20
Rate for Payer: Meridian Medicaid	$46.29
Rate for Payer: Priority Health Choice Medicaid	$44.09
Rate for Payer: Priority Health Cigna Priority Health	$125.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$82.20
Rate for Payer: Priority Health Narrow Network	$82.20
Rate for Payer: Priority Health SBD	$82.20
Rate for Payer: UMR Bronson Commercial	$82.34

PR DESTRUCTION BENIGN LESIONS UP TO 14

Facility

$179.00

Service Code	CPT 17110
Hospital Charge Code	17110
Hospital Revenue Code	521
Min. Negotiated Rate	$78.76
Max. Negotiated Rate	$161.10
Rate for Payer: Aetna American Axle	$116.35
Rate for Payer: Aetna Commercial	$152.15
Rate for Payer: Aetna New Business (MI Preferred)	$116.35
Rate for Payer: Cash Price	$143.20
Rate for Payer: Cofinity Commercial	$125.30
Rate for Payer: Cofinity Commercial	$153.94
Rate for Payer: Encore Health Key Benefits Commercial	$143.20
Rate for Payer: Healthscope Commercial	$161.10
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial	$125.30
Rate for Payer: Lakeland Regional Health Systems Commercial	$134.25
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$152.15
Rate for Payer: PHP Commercial	$152.15
Rate for Payer: Priority Health Cigna Priority Health	$125.30
Rate for Payer: Priority Health SBD	$112.77
Rate for Payer: UMR Bronson Commercial	$78.76
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$134.25

PR DESTRUCTION BENIGN LESIONS UP TO 14

Facility

$179.00

Service Code	CPT 17110
Hospital Charge Code	17110
Hospital Revenue Code	521
Min. Negotiated Rate	$66.23
Max. Negotiated Rate	$560.20
Rate for Payer: Aetna American Axle	$116.35
Rate for Payer: Aetna Commercial	$152.15
Rate for Payer: Aetna Medicare	$185.07
Rate for Payer: Aetna New Business (MI Preferred)	$116.35
Rate for Payer: Allen County Amish Medical Aid Commercial	$222.44
Rate for Payer: Amish Plain Church Group Commercial	$222.44
Rate for Payer: BCBS Complete	$102.21
Rate for Payer: BCBS MAPPO	$177.95
Rate for Payer: BCBS Trust/PPO	$99.55
Rate for Payer: BCN Medicare Advantage	$177.95
Rate for Payer: Cash Price	$143.20
Rate for Payer: Cash Price	$143.20
Rate for Payer: Cofinity Commercial	$125.30
Rate for Payer: Cofinity Commercial	$153.94
Rate for Payer: Encore Health Key Benefits Commercial	$143.20
Rate for Payer: Health Alliance Plan Medicare Advantage	$177.95
Rate for Payer: Healthscope Commercial	$161.10
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial	$125.30
Rate for Payer: Lakeland Regional Health Systems Commercial	$134.25
Rate for Payer: Mclaren Medicaid	$97.34
Rate for Payer: Mclaren Medicare	$177.95
Rate for Payer: Meridian Medicaid	$102.21
Rate for Payer: Meridian Wellcare - Medicare Advantage	$186.85
Rate for Payer: MI Amish Medical Board Commercial	$204.64
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$152.15
Rate for Payer: PACE Medicare	$169.05
Rate for Payer: PACE SWMI	$177.95
Rate for Payer: PHP Commercial	$152.15
Rate for Payer: PHP Medicare Advantage	$177.95
Rate for Payer: Priority Health Choice Medicaid	$97.34
Rate for Payer: Priority Health Cigna Priority Health	$125.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$560.20
Rate for Payer: Priority Health Medicare	$177.95
Rate for Payer: Priority Health Narrow Network	$448.16
Rate for Payer: Priority Health SBD	$112.77
Rate for Payer: Railroad Medicare Medicare	$177.95
Rate for Payer: UHC All Payor (Choice/PPO)	$74.56
Rate for Payer: UHC Dual Complete DSNP	$177.95
Rate for Payer: UHC Exchange	$67.78
Rate for Payer: UHC Medicare Advantage	$183.29
Rate for Payer: UMR Bronson Commercial	$66.23
Rate for Payer: VA VA	$177.95
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$134.25

PR DESTRUCTION CUTANEOUS VASC PROLIFERATIVE <10CM

Professional

Both

$618.00

Service Code	HCPCS 17106
Min. Negotiated Rate	$177.00
Max. Negotiated Rate	$947.65
Rate for Payer: Aetna Commercial	$291.61
Rate for Payer: BCBS Complete	$185.85
Rate for Payer: BCBS Trust/PPO	$947.65
Rate for Payer: Cash Price	$494.40
Rate for Payer: Cash Price	$494.40
Rate for Payer: Meridian Medicaid	$185.85
Rate for Payer: Priority Health Choice Medicaid	$177.00
Rate for Payer: Priority Health Cigna Priority Health	$432.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$337.46
Rate for Payer: Priority Health Narrow Network	$337.46
Rate for Payer: Priority Health SBD	$337.46
Rate for Payer: UMR Bronson Commercial	$284.28

PR DESTRUCTION INTERNAL HEMORRHOID THERMAL ENERGY

Professional

Both

$331.00

Service Code	HCPCS 46930
Min. Negotiated Rate	$97.55
Max. Negotiated Rate	$1,115.77
Rate for Payer: Aetna Commercial	$200.96
Rate for Payer: BCBS Complete	$102.43
Rate for Payer: BCBS Trust/PPO	$1,115.77
Rate for Payer: Cash Price	$264.80
Rate for Payer: Cash Price	$264.80
Rate for Payer: Meridian Medicaid	$102.43
Rate for Payer: Priority Health Choice Medicaid	$97.55
Rate for Payer: Priority Health Cigna Priority Health	$231.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$266.94
Rate for Payer: Priority Health Narrow Network	$266.94
Rate for Payer: Priority Health SBD	$266.94
Rate for Payer: UMR Bronson Commercial	$152.26

PR DESTRUCTION LESION LID MARGIN </ 1 CM

Professional

Both

$477.00

Service Code	HCPCS 67850
Min. Negotiated Rate	$83.28
Max. Negotiated Rate	$347.09
Rate for Payer: Aetna Commercial	$169.96
Rate for Payer: BCBS Complete	$87.44
Rate for Payer: BCBS Trust/PPO	$347.09
Rate for Payer: Cash Price	$381.60
Rate for Payer: Cash Price	$381.60
Rate for Payer: Meridian Medicaid	$87.44
Rate for Payer: Priority Health Choice Medicaid	$83.28
Rate for Payer: Priority Health Cigna Priority Health	$333.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$227.73
Rate for Payer: Priority Health Narrow Network	$227.73
Rate for Payer: Priority Health SBD	$227.73
Rate for Payer: UMR Bronson Commercial	$219.42

PR DESTRUCTION LESIONS VULVA EXTENSIVE

Professional

Both

$569.00

Service Code	HCPCS 56515
Min. Negotiated Rate	$136.96
Max. Negotiated Rate	$2,047.16
Rate for Payer: Aetna Commercial	$249.32
Rate for Payer: BCBS Complete	$143.81
Rate for Payer: BCBS Trust/PPO	$2,047.16
Rate for Payer: Cash Price	$455.20
Rate for Payer: Cash Price	$455.20
Rate for Payer: Meridian Medicaid	$143.81
Rate for Payer: Priority Health Choice Medicaid	$136.96
Rate for Payer: Priority Health Cigna Priority Health	$398.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$302.99
Rate for Payer: Priority Health Narrow Network	$302.99
Rate for Payer: Priority Health SBD	$302.99
Rate for Payer: UMR Bronson Commercial	$261.74

PR DESTRUCTION LESIONS VULVA SIMPLE

Professional

Both

$376.00

Service Code	HCPCS 56501
Min. Negotiated Rate	$86.27
Max. Negotiated Rate	$1,962.11
Rate for Payer: Aetna Commercial	$152.26
Rate for Payer: BCBS Complete	$90.58
Rate for Payer: BCBS Trust/PPO	$1,962.11
Rate for Payer: Cash Price	$300.80
Rate for Payer: Cash Price	$300.80
Rate for Payer: Meridian Medicaid	$90.58
Rate for Payer: Priority Health Choice Medicaid	$86.27
Rate for Payer: Priority Health Cigna Priority Health	$263.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$190.80
Rate for Payer: Priority Health Narrow Network	$190.80
Rate for Payer: Priority Health SBD	$190.80
Rate for Payer: UMR Bronson Commercial	$172.96

PR DESTRUCTION MALIGNANT LESION F/E/E/N/L/M 0.5CM/<

Professional

Both

$229.00

Service Code	HCPCS 17280
Min. Negotiated Rate	$55.59
Max. Negotiated Rate	$3,247.68
Rate for Payer: Aetna Commercial	$92.27
Rate for Payer: BCBS Complete	$58.37
Rate for Payer: BCBS Trust/PPO	$3,247.68
Rate for Payer: Cash Price	$183.20
Rate for Payer: Cash Price	$183.20
Rate for Payer: Meridian Medicaid	$58.37
Rate for Payer: Priority Health Choice Medicaid	$55.59
Rate for Payer: Priority Health Cigna Priority Health	$160.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$105.22
Rate for Payer: Priority Health Narrow Network	$105.22
Rate for Payer: Priority Health SBD	$105.22
Rate for Payer: UMR Bronson Commercial	$105.34

PR DESTRUCTION MALIGNANT LESION S/N/H/F/G 0.5 CM/>

Professional

Both

$245.00

Service Code	HCPCS 17270
Min. Negotiated Rate	$61.13
Max. Negotiated Rate	$3,247.68
Rate for Payer: Aetna Commercial	$101.20
Rate for Payer: BCBS Complete	$64.19
Rate for Payer: BCBS Trust/PPO	$3,247.68
Rate for Payer: Cash Price	$196.00
Rate for Payer: Cash Price	$196.00
Rate for Payer: Meridian Medicaid	$64.19
Rate for Payer: Priority Health Choice Medicaid	$61.13
Rate for Payer: Priority Health Cigna Priority Health	$171.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$116.74
Rate for Payer: Priority Health Narrow Network	$116.74
Rate for Payer: Priority Health SBD	$116.74
Rate for Payer: UMR Bronson Commercial	$112.70

PR DESTRUCTION MALIGNANT LESION S/N/H/F/G 0.6-1.0CM

Professional

Both

$266.00

Service Code	HCPCS 17271
Min. Negotiated Rate	$67.10
Max. Negotiated Rate	$5,054.50
Rate for Payer: Aetna Commercial	$111.95
Rate for Payer: BCBS Complete	$70.46
Rate for Payer: BCBS Trust/PPO	$5,054.50
Rate for Payer: Cash Price	$212.80
Rate for Payer: Cash Price	$212.80
Rate for Payer: Meridian Medicaid	$70.46
Rate for Payer: Priority Health Choice Medicaid	$67.10
Rate for Payer: Priority Health Cigna Priority Health	$186.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$128.66
Rate for Payer: Priority Health Narrow Network	$128.66
Rate for Payer: Priority Health SBD	$128.66
Rate for Payer: UMR Bronson Commercial	$122.36

PR DESTRUCTION MALIGNANT LESION S/N/H/F/G 1.1-2.0CM

Professional

Both

$302.00

Service Code	HCPCS 17272
Min. Negotiated Rate	$77.32
Max. Negotiated Rate	$29,358.48
Rate for Payer: Aetna Commercial	$129.04
Rate for Payer: BCBS Complete	$81.19
Rate for Payer: BCBS Trust/PPO	$29,358.48
Rate for Payer: Cash Price	$241.60
Rate for Payer: Cash Price	$241.60
Rate for Payer: Meridian Medicaid	$81.19
Rate for Payer: Priority Health Choice Medicaid	$77.32
Rate for Payer: Priority Health Cigna Priority Health	$211.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$147.57
Rate for Payer: Priority Health Narrow Network	$147.57
Rate for Payer: Priority Health SBD	$147.57
Rate for Payer: UMR Bronson Commercial	$138.92

PR DESTRUCTION MALIGNANT LESION S/N/H/F/G 2.1-3.0CM

Professional

Both

$337.00

Service Code	HCPCS 17273
Min. Negotiated Rate	$87.33
Max. Negotiated Rate	$456.13
Rate for Payer: Aetna Commercial	$146.89
Rate for Payer: BCBS Complete	$91.70
Rate for Payer: BCBS Trust/PPO	$456.13
Rate for Payer: Cash Price	$269.60
Rate for Payer: Cash Price	$269.60
Rate for Payer: Meridian Medicaid	$91.70
Rate for Payer: Priority Health Choice Medicaid	$87.33
Rate for Payer: Priority Health Cigna Priority Health	$235.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$166.88
Rate for Payer: Priority Health Narrow Network	$166.88
Rate for Payer: Priority Health SBD	$166.88
Rate for Payer: UMR Bronson Commercial	$155.02

PR DESTRUCTION MALIGNANT LESION S/N/H/F/G 3.1-4.0CM

Professional

Both

$425.00

Service Code	HCPCS 17274
Min. Negotiated Rate	$106.50
Max. Negotiated Rate	$6,178.65
Rate for Payer: Aetna Commercial	$179.26
Rate for Payer: BCBS Complete	$111.82
Rate for Payer: BCBS Trust/PPO	$6,178.65
Rate for Payer: Cash Price	$340.00
Rate for Payer: Cash Price	$340.00
Rate for Payer: Meridian Medicaid	$111.82
Rate for Payer: Priority Health Choice Medicaid	$106.50
Rate for Payer: Priority Health Cigna Priority Health	$297.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$204.29
Rate for Payer: Priority Health Narrow Network	$204.29
Rate for Payer: Priority Health SBD	$204.29
Rate for Payer: UMR Bronson Commercial	$195.50

PR DESTRUCTION MALIGNANT LESION T/A/L 0.5 CM/<

Professional

Both

$165.00

Service Code	HCPCS 17260
Min. Negotiated Rate	$45.16
Max. Negotiated Rate	$947.65
Rate for Payer: Aetna Commercial	$74.85
Rate for Payer: BCBS Complete	$47.42
Rate for Payer: BCBS Trust/PPO	$947.65
Rate for Payer: Cash Price	$132.00
Rate for Payer: Cash Price	$132.00
Rate for Payer: Meridian Medicaid	$47.42
Rate for Payer: Priority Health Choice Medicaid	$45.16
Rate for Payer: Priority Health Cigna Priority Health	$115.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$86.31
Rate for Payer: Priority Health Narrow Network	$86.31
Rate for Payer: Priority Health SBD	$86.31
Rate for Payer: UMR Bronson Commercial	$75.90

PR DESTRUCTION MAL LESION F/E/E/N/L/M 0.6-1.0CM

Professional

Both

$289.00

Service Code	HCPCS 17281
Min. Negotiated Rate	$75.40
Max. Negotiated Rate	$456.13
Rate for Payer: Aetna Commercial	$125.70
Rate for Payer: BCBS Complete	$79.17
Rate for Payer: BCBS Trust/PPO	$456.13
Rate for Payer: Cash Price	$231.20
Rate for Payer: Cash Price	$231.20
Rate for Payer: Meridian Medicaid	$79.17
Rate for Payer: Priority Health Choice Medicaid	$75.40
Rate for Payer: Priority Health Cigna Priority Health	$202.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$144.27
Rate for Payer: Priority Health Narrow Network	$144.27
Rate for Payer: Priority Health SBD	$144.27
Rate for Payer: UMR Bronson Commercial	$132.94

Know your out-of-pocket cost for care.

All Charges