Bronson Methodist Hospital

All Charges

Charge

Type

Setting

Price

PR DIR RPR RUPTD ANEURSM ABDOM AORTA W/VISCERA VSLS

Professional

Both

$5,390.00

Service Code	HCPCS 35092
Min. Negotiated Rate	$1,617.31
Max. Negotiated Rate	$4,007.77
Rate for Payer: Aetna Commercial	$3,485.74
Rate for Payer: BCBS Complete	$1,698.18
Rate for Payer: BCBS Trust/PPO	$2,136.58
Rate for Payer: Cash Price	$4,312.00
Rate for Payer: Cash Price	$4,312.00
Rate for Payer: Meridian Medicaid	$1,698.18
Rate for Payer: Priority Health Choice Medicaid	$1,617.31
Rate for Payer: Priority Health Cigna Priority Health	$3,773.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$4,007.77
Rate for Payer: Priority Health Narrow Network	$4,007.77
Rate for Payer: Priority Health SBD	$4,007.77
Rate for Payer: UMR Bronson Commercial	$2,479.40

PR DIR RPR RUPTD ANEURSM HEPATIC/CELIAC/RENAL/MESEN

Professional

Both

$3,783.00

Service Code	HCPCS 35122
Min. Negotiated Rate	$1,178.96
Max. Negotiated Rate	$2,930.03
Rate for Payer: Aetna Commercial	$2,544.07
Rate for Payer: BCBS Complete	$1,237.91
Rate for Payer: BCBS Trust/PPO	$1,197.66
Rate for Payer: Cash Price	$3,026.40
Rate for Payer: Cash Price	$3,026.40
Rate for Payer: Meridian Medicaid	$1,237.91
Rate for Payer: Priority Health Choice Medicaid	$1,178.96
Rate for Payer: Priority Health Cigna Priority Health	$2,648.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,930.03
Rate for Payer: Priority Health Narrow Network	$2,930.03
Rate for Payer: Priority Health SBD	$2,930.03
Rate for Payer: UMR Bronson Commercial	$1,740.18

PR DIR RPR RUPTD ANEURYSM ABDOM AORTA W/ILIAC VSLS

Professional

Both

$3,490.00

Service Code	HCPCS 35103
Min. Negotiated Rate	$621.81
Max. Negotiated Rate	$3,446.55
Rate for Payer: Aetna Commercial	$2,999.96
Rate for Payer: BCBS Complete	$1,450.38
Rate for Payer: BCBS Trust/PPO	$621.81
Rate for Payer: Cash Price	$2,792.00
Rate for Payer: Cash Price	$2,792.00
Rate for Payer: Meridian Medicaid	$1,450.38
Rate for Payer: Priority Health Choice Medicaid	$1,381.31
Rate for Payer: Priority Health Cigna Priority Health	$2,443.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$3,446.55
Rate for Payer: Priority Health Narrow Network	$3,446.55
Rate for Payer: Priority Health SBD	$3,446.55
Rate for Payer: UMR Bronson Commercial	$1,605.40

PR DIR RPR RUPTD ANEURYSM ABDOMINAL AORTA

Professional

Both

$4,202.00

Service Code	HCPCS 35082
Min. Negotiated Rate	$750.19
Max. Negotiated Rate	$3,356.12
Rate for Payer: Aetna Commercial	$2,925.76
Rate for Payer: BCBS Complete	$1,414.59
Rate for Payer: BCBS Trust/PPO	$750.19
Rate for Payer: Cash Price	$3,361.60
Rate for Payer: Cash Price	$3,361.60
Rate for Payer: Meridian Medicaid	$1,414.59
Rate for Payer: Priority Health Choice Medicaid	$1,347.23
Rate for Payer: Priority Health Cigna Priority Health	$2,941.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$3,356.12
Rate for Payer: Priority Health Narrow Network	$3,356.12
Rate for Payer: Priority Health SBD	$3,356.12
Rate for Payer: UMR Bronson Commercial	$1,932.92

PR DIR RPR RUPTD ANEURYSM AXIL-BRACHIAL ARM INCIS

Professional

Both

$3,850.00

Service Code	HCPCS 35013
Min. Negotiated Rate	$793.43
Max. Negotiated Rate	$2,695.00
Rate for Payer: Aetna Commercial	$1,693.49
Rate for Payer: BCBS Complete	$833.10
Rate for Payer: BCBS Trust/PPO	$1,152.22
Rate for Payer: Cash Price	$3,080.00
Rate for Payer: Cash Price	$3,080.00
Rate for Payer: Meridian Medicaid	$833.10
Rate for Payer: Priority Health Choice Medicaid	$793.43
Rate for Payer: Priority Health Cigna Priority Health	$2,695.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,976.76
Rate for Payer: Priority Health Narrow Network	$1,976.76
Rate for Payer: Priority Health SBD	$1,976.76
Rate for Payer: UMR Bronson Commercial	$1,771.00

PR DIR RPR RUPTD ANEURYSM CAROTID-SUBCLAVIAN ARTERY

Professional

Both

$2,492.00

Service Code	HCPCS 35002
Min. Negotiated Rate	$711.21
Max. Negotiated Rate	$2,959.01
Rate for Payer: Aetna Commercial	$1,529.14
Rate for Payer: BCBS Complete	$746.77
Rate for Payer: BCBS Trust/PPO	$2,959.01
Rate for Payer: Cash Price	$1,993.60
Rate for Payer: Cash Price	$1,993.60
Rate for Payer: Meridian Medicaid	$746.77
Rate for Payer: Priority Health Choice Medicaid	$711.21
Rate for Payer: Priority Health Cigna Priority Health	$1,744.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,767.16
Rate for Payer: Priority Health Narrow Network	$1,767.16
Rate for Payer: Priority Health SBD	$1,767.16
Rate for Payer: UMR Bronson Commercial	$1,146.32

PR DIR RPR RUPTD ANEURYSM & GRAFT ILIAC ARTERY

Professional

Both

$3,384.00

Service Code	HCPCS 35132
Min. Negotiated Rate	$1,019.21
Max. Negotiated Rate	$2,534.79
Rate for Payer: Aetna Commercial	$2,198.85
Rate for Payer: BCBS Complete	$1,070.17
Rate for Payer: BCBS Trust/PPO	$2,010.18
Rate for Payer: Cash Price	$2,707.20
Rate for Payer: Cash Price	$2,707.20
Rate for Payer: Meridian Medicaid	$1,070.17
Rate for Payer: Priority Health Choice Medicaid	$1,019.21
Rate for Payer: Priority Health Cigna Priority Health	$2,368.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,534.79
Rate for Payer: Priority Health Narrow Network	$2,534.79
Rate for Payer: Priority Health SBD	$2,534.79
Rate for Payer: UMR Bronson Commercial	$1,556.64

PR DIR RPR RUPTD ANEURYSM & GRF COMMON FEMORAL ART

Professional

Both

$2,559.00

Service Code	HCPCS 35142
Min. Negotiated Rate	$571.62
Max. Negotiated Rate	$2,051.23
Rate for Payer: Aetna Commercial	$1,780.33
Rate for Payer: BCBS Complete	$864.41
Rate for Payer: BCBS Trust/PPO	$571.62
Rate for Payer: Cash Price	$2,047.20
Rate for Payer: Cash Price	$2,047.20
Rate for Payer: Meridian Medicaid	$864.41
Rate for Payer: Priority Health Choice Medicaid	$823.25
Rate for Payer: Priority Health Cigna Priority Health	$1,791.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,051.23
Rate for Payer: Priority Health Narrow Network	$2,051.23
Rate for Payer: Priority Health SBD	$2,051.23
Rate for Payer: UMR Bronson Commercial	$1,177.14

PR DIR RPR RUPTD ANEURYSM & GRF POPLITEAL ARTERY

Professional

Both

$2,683.00

Service Code	HCPCS 35152
Min. Negotiated Rate	$872.02
Max. Negotiated Rate	$2,435.46
Rate for Payer: Aetna Commercial	$1,879.21
Rate for Payer: BCBS Complete	$915.62
Rate for Payer: BCBS Trust/PPO	$2,435.46
Rate for Payer: Cash Price	$2,146.40
Rate for Payer: Cash Price	$2,146.40
Rate for Payer: Meridian Medicaid	$915.62
Rate for Payer: Priority Health Choice Medicaid	$872.02
Rate for Payer: Priority Health Cigna Priority Health	$1,878.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,168.79
Rate for Payer: Priority Health Narrow Network	$2,168.79
Rate for Payer: Priority Health SBD	$2,168.79
Rate for Payer: UMR Bronson Commercial	$1,234.18

PR DIR RPR RUPTD ANEURYSM RADIAL/ULNAR ARTERY

Professional

Both

$3,357.00

Service Code	HCPCS 35045
Min. Negotiated Rate	$606.84
Max. Negotiated Rate	$2,349.90
Rate for Payer: Aetna Commercial	$1,308.16
Rate for Payer: BCBS Complete	$637.18
Rate for Payer: BCBS Trust/PPO	$1,582.22
Rate for Payer: Cash Price	$2,685.60
Rate for Payer: Cash Price	$2,685.60
Rate for Payer: Meridian Medicaid	$637.18
Rate for Payer: Priority Health Choice Medicaid	$606.84
Rate for Payer: Priority Health Cigna Priority Health	$2,349.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,512.35
Rate for Payer: Priority Health Narrow Network	$1,512.35
Rate for Payer: Priority Health SBD	$1,512.35
Rate for Payer: UMR Bronson Commercial	$1,544.22

PR DISARTICULATION HIP

Professional

Both

$5,325.00

Service Code	HCPCS 27295
Min. Negotiated Rate	$808.12
Max. Negotiated Rate	$3,727.50
Rate for Payer: Aetna Commercial	$1,675.17
Rate for Payer: BCBS Complete	$848.53
Rate for Payer: BCBS Trust/PPO	$3,334.10
Rate for Payer: Cash Price	$4,260.00
Rate for Payer: Cash Price	$4,260.00
Rate for Payer: Meridian Medicaid	$848.53
Rate for Payer: Priority Health Choice Medicaid	$808.12
Rate for Payer: Priority Health Cigna Priority Health	$3,727.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,920.56
Rate for Payer: Priority Health Narrow Network	$1,920.56
Rate for Payer: Priority Health SBD	$1,920.56
Rate for Payer: UMR Bronson Commercial	$2,449.50

PR DISARTICULATION KNEE

Professional

Both

$2,875.00

Service Code	HCPCS 27598
Min. Negotiated Rate	$442.83
Max. Negotiated Rate	$2,012.50
Rate for Payer: Aetna Commercial	$947.37
Rate for Payer: BCBS Complete	$464.97
Rate for Payer: BCBS Trust/PPO	$797.73
Rate for Payer: Cash Price	$2,300.00
Rate for Payer: Cash Price	$2,300.00
Rate for Payer: Meridian Medicaid	$464.97
Rate for Payer: Priority Health Choice Medicaid	$442.83
Rate for Payer: Priority Health Cigna Priority Health	$2,012.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,059.60
Rate for Payer: Priority Health Narrow Network	$1,059.60
Rate for Payer: Priority Health SBD	$1,059.60
Rate for Payer: UMR Bronson Commercial	$1,322.50

PR DISARTICULATION SHOULDER

Professional

Both

$1,957.00

Service Code	HCPCS 23920
Min. Negotiated Rate	$491.15
Max. Negotiated Rate	$1,718.84
Rate for Payer: Aetna Commercial	$1,500.60
Rate for Payer: BCBS Complete	$759.07
Rate for Payer: BCBS Trust/PPO	$491.15
Rate for Payer: Cash Price	$1,565.60
Rate for Payer: Cash Price	$1,565.60
Rate for Payer: Meridian Medicaid	$759.07
Rate for Payer: Priority Health Choice Medicaid	$722.92
Rate for Payer: Priority Health Cigna Priority Health	$1,369.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,718.84
Rate for Payer: Priority Health Narrow Network	$1,718.84
Rate for Payer: Priority Health SBD	$1,718.84
Rate for Payer: UMR Bronson Commercial	$900.22

PR DISARTICULATION THROUGH WRIST

Professional

Both

$1,404.00

Service Code	HCPCS 25920
Min. Negotiated Rate	$129.43
Max. Negotiated Rate	$1,128.03
Rate for Payer: Aetna Commercial	$967.98
Rate for Payer: BCBS Complete	$496.72
Rate for Payer: BCBS Trust/PPO	$129.43
Rate for Payer: Cash Price	$1,123.20
Rate for Payer: Cash Price	$1,123.20
Rate for Payer: Meridian Medicaid	$496.72
Rate for Payer: Priority Health Choice Medicaid	$473.07
Rate for Payer: Priority Health Cigna Priority Health	$982.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,128.03
Rate for Payer: Priority Health Narrow Network	$1,128.03
Rate for Payer: Priority Health SBD	$1,128.03
Rate for Payer: UMR Bronson Commercial	$645.84

PR DISARTICULATION THRU WRIST RE-AMPUTATION

Professional

Both

$2,313.00

Service Code	HCPCS 25924
Min. Negotiated Rate	$69.19
Max. Negotiated Rate	$1,619.10
Rate for Payer: Aetna Commercial	$945.90
Rate for Payer: BCBS Complete	$485.32
Rate for Payer: BCBS Trust/PPO	$69.19
Rate for Payer: Cash Price	$1,850.40
Rate for Payer: Cash Price	$1,850.40
Rate for Payer: Meridian Medicaid	$485.32
Rate for Payer: Priority Health Choice Medicaid	$462.21
Rate for Payer: Priority Health Cigna Priority Health	$1,619.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,101.99
Rate for Payer: Priority Health Narrow Network	$1,101.99
Rate for Payer: Priority Health SBD	$1,101.99
Rate for Payer: UMR Bronson Commercial	$1,063.98

PR DISCECTOMY ANT DCMPRN CORD CERVICAL 1 NTRSPC

Professional

Both

$5,633.00

Service Code	HCPCS 63075
Min. Negotiated Rate	$170.11
Max. Negotiated Rate	$3,943.10
Rate for Payer: Aetna Commercial	$1,752.58
Rate for Payer: BCBS Complete	$917.86
Rate for Payer: BCBS Trust/PPO	$170.11
Rate for Payer: Cash Price	$4,506.40
Rate for Payer: Cash Price	$4,506.40
Rate for Payer: Meridian Medicaid	$917.86
Rate for Payer: Priority Health Choice Medicaid	$874.15
Rate for Payer: Priority Health Cigna Priority Health	$3,943.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,312.45
Rate for Payer: Priority Health Narrow Network	$2,312.45
Rate for Payer: Priority Health SBD	$2,312.45
Rate for Payer: UMR Bronson Commercial	$2,591.18

PR DISCECTOMY ANT DCMPRN CORD CERVICAL EA NTRSPC

Professional

Both

$1,890.00

Service Code	HCPCS 63076
Min. Negotiated Rate	$153.79
Max. Negotiated Rate	$1,323.00
Rate for Payer: Aetna Commercial	$316.56
Rate for Payer: BCBS Complete	$161.48
Rate for Payer: BCBS Trust/PPO	$174.34
Rate for Payer: Cash Price	$1,512.00
Rate for Payer: Cash Price	$1,512.00
Rate for Payer: Meridian Medicaid	$161.48
Rate for Payer: Priority Health Choice Medicaid	$153.79
Rate for Payer: Priority Health Cigna Priority Health	$1,323.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$409.37
Rate for Payer: Priority Health Narrow Network	$409.37
Rate for Payer: Priority Health SBD	$409.37
Rate for Payer: UMR Bronson Commercial	$869.40

PR DISCECTOMY ANT DCMPRN CORD THORACIC 1 NTRSPC

Professional

Both

$5,580.00

Service Code	HCPCS 63077
Min. Negotiated Rate	$145.28
Max. Negotiated Rate	$3,906.00
Rate for Payer: Aetna Commercial	$1,935.47
Rate for Payer: BCBS Complete	$982.04
Rate for Payer: BCBS Trust/PPO	$145.28
Rate for Payer: Cash Price	$4,464.00
Rate for Payer: Cash Price	$4,464.00
Rate for Payer: Meridian Medicaid	$982.04
Rate for Payer: Priority Health Choice Medicaid	$935.28
Rate for Payer: Priority Health Cigna Priority Health	$3,906.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,598.39
Rate for Payer: Priority Health Narrow Network	$2,598.39
Rate for Payer: Priority Health SBD	$2,598.39
Rate for Payer: UMR Bronson Commercial	$2,566.80

PR DISEASE MANAGEMENT PROGRAM

Professional

Both

$450.00

Service Code	HCPCS S0315
Min. Negotiated Rate	$85.00
Max. Negotiated Rate	$315.00
Rate for Payer: Aetna Commercial	$85.00
Rate for Payer: BCBS Complete	$180.00
Rate for Payer: BCBS Trust/PPO	$111.47
Rate for Payer: Cash Price	$360.00
Rate for Payer: Cash Price	$360.00
Rate for Payer: Priority Health Cigna Priority Health	$315.00
Rate for Payer: UMR Bronson Commercial	$207.00

PR DISEASE MGMT PER DIEM

Professional

Both

$100.00

Service Code	HCPCS S0317
Min. Negotiated Rate	$40.00
Max. Negotiated Rate	$175.00
Rate for Payer: Aetna Commercial	$175.00
Rate for Payer: Aetna Commercial	$175.00
Rate for Payer: BCBS Complete	$60.00
Rate for Payer: BCBS Complete	$40.00
Rate for Payer: BCBS Trust/PPO	$58.11
Rate for Payer: BCBS Trust/PPO	$58.11
Rate for Payer: Cash Price	$80.00
Rate for Payer: Cash Price	$80.00
Rate for Payer: Cash Price	$120.00
Rate for Payer: Cash Price	$120.00
Rate for Payer: Priority Health Cigna Priority Health	$105.00
Rate for Payer: Priority Health Cigna Priority Health	$70.00
Rate for Payer: UMR Bronson Commercial	$69.00
Rate for Payer: UMR Bronson Commercial	$46.00

PR DISE DYN EVAL SLEEP DISORDERED BREATHING FLX DX

Professional

Both

$223.00

Service Code	HCPCS 42975
Min. Negotiated Rate	$61.98
Max. Negotiated Rate	$284.23
Rate for Payer: Aetna Commercial	$150.00
Rate for Payer: BCBS Complete	$65.08
Rate for Payer: BCBS Trust/PPO	$284.23
Rate for Payer: Cash Price	$178.40
Rate for Payer: Cash Price	$178.40
Rate for Payer: Meridian Medicaid	$65.08
Rate for Payer: Priority Health Choice Medicaid	$61.98
Rate for Payer: Priority Health Cigna Priority Health	$156.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$168.16
Rate for Payer: Priority Health Narrow Network	$168.16
Rate for Payer: Priority Health SBD	$168.16
Rate for Payer: UMR Bronson Commercial	$102.58

PR DISPENSING FEE BINAURAL

Professional

Both

$475.00

Service Code	HCPCS V5160
Min. Negotiated Rate	$190.00
Max. Negotiated Rate	$332.50
Rate for Payer: Aetna Commercial	$289.59
Rate for Payer: BCBS Complete	$190.00
Rate for Payer: Cash Price	$380.00
Rate for Payer: Cash Price	$380.00
Rate for Payer: Priority Health Cigna Priority Health	$332.50
Rate for Payer: UMR Bronson Commercial	$218.50

PR DISPENSING FEE, MONAURAL

Professional

Both

$275.00

Service Code	HCPCS V5241
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$192.50
Rate for Payer: Aetna Commercial	$0.01
Rate for Payer: BCBS Complete	$110.00
Rate for Payer: Cash Price	$220.00
Rate for Payer: Cash Price	$220.00
Rate for Payer: Priority Health Cigna Priority Health	$192.50
Rate for Payer: UMR Bronson Commercial	$126.50

PR DISP FEE CONTRALATERAL BINAU

Professional

Both

$475.00

Service Code	HCPCS V5240
Min. Negotiated Rate	$190.00
Max. Negotiated Rate	$332.50
Rate for Payer: Aetna Commercial	$248.26
Rate for Payer: BCBS Complete	$190.00
Rate for Payer: Cash Price	$380.00
Rate for Payer: Cash Price	$380.00
Rate for Payer: Priority Health Cigna Priority Health	$332.50
Rate for Payer: UMR Bronson Commercial	$218.50

PR DISP FEE CONTRALATERAL MONAU

Professional

Both

$275.00

Service Code	HCPCS V5200
Min. Negotiated Rate	$110.00
Max. Negotiated Rate	$239.68
Rate for Payer: Aetna Commercial	$239.68
Rate for Payer: BCBS Complete	$110.00
Rate for Payer: Cash Price	$220.00
Rate for Payer: Cash Price	$220.00
Rate for Payer: Priority Health Cigna Priority Health	$192.50
Rate for Payer: UMR Bronson Commercial	$126.50

Know your out-of-pocket cost for care.

All Charges