Bronson Methodist Hospital

All Charges

Charge

Type

Setting

Price

PR ESOPHAGOSCOPY FLEX TRANSORAL INJECTION VARICES

Professional

Both

$1,082.00

Service Code	HCPCS 43204
Min. Negotiated Rate	$84.99
Max. Negotiated Rate	$757.40
Rate for Payer: Aetna Commercial	$179.22
Rate for Payer: BCBS Complete	$89.24
Rate for Payer: BCBS Trust/PPO	$249.36
Rate for Payer: Cash Price	$865.60
Rate for Payer: Cash Price	$865.60
Rate for Payer: Meridian Medicaid	$89.24
Rate for Payer: Priority Health Choice Medicaid	$84.99
Rate for Payer: Priority Health Cigna Priority Health	$757.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$233.42
Rate for Payer: Priority Health Narrow Network	$233.42
Rate for Payer: Priority Health SBD	$233.42
Rate for Payer: UMR Bronson Commercial	$497.72

PR ESOPHAGOSCOPY FLEX TRANSORAL LESION ABLATION

Professional

Both

$626.00

Service Code	HCPCS 43229
Min. Negotiated Rate	$123.53
Max. Negotiated Rate	$438.20
Rate for Payer: Aetna Commercial	$262.30
Rate for Payer: BCBS Complete	$129.94
Rate for Payer: BCBS Trust/PPO	$123.53
Rate for Payer: Cash Price	$500.80
Rate for Payer: Cash Price	$500.80
Rate for Payer: Meridian Medicaid	$129.94
Rate for Payer: Priority Health Choice Medicaid	$123.75
Rate for Payer: Priority Health Cigna Priority Health	$438.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$339.26
Rate for Payer: Priority Health Narrow Network	$339.26
Rate for Payer: Priority Health SBD	$339.26
Rate for Payer: UMR Bronson Commercial	$287.96

PR ESOPHAGOSCOPY,INSERT TUBE/STENT

Professional

Both

$1,467.00

Service Code	HCPCS 43219
Min. Negotiated Rate	$586.80
Max. Negotiated Rate	$1,026.90
Rate for Payer: BCBS Complete	$586.80
Rate for Payer: Cash Price	$1,173.60
Rate for Payer: Priority Health Cigna Priority Health	$1,026.90
Rate for Payer: UMR Bronson Commercial	$674.82

PR ESOPHAGOSCOPY INTRA/TRANSMURAL NEEDLE ASPIRAT/BX

Professional

Both

$1,014.00

Service Code	HCPCS 43232
Min. Negotiated Rate	$81.89
Max. Negotiated Rate	$709.80
Rate for Payer: Aetna Commercial	$264.70
Rate for Payer: BCBS Complete	$131.28
Rate for Payer: BCBS Trust/PPO	$81.89
Rate for Payer: Cash Price	$811.20
Rate for Payer: Cash Price	$811.20
Rate for Payer: Meridian Medicaid	$131.28
Rate for Payer: Priority Health Choice Medicaid	$125.03
Rate for Payer: Priority Health Cigna Priority Health	$709.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$340.44
Rate for Payer: Priority Health Narrow Network	$340.44
Rate for Payer: Priority Health SBD	$340.44
Rate for Payer: UMR Bronson Commercial	$466.44

PR ESOPHAGOSCOPY RIGID TRANSORAL BALLOON DILATION

Professional

Both

$374.00

Service Code	HCPCS 43195
Min. Negotiated Rate	$29.06
Max. Negotiated Rate	$323.98
Rate for Payer: Aetna Commercial	$242.98
Rate for Payer: BCBS Complete	$123.90
Rate for Payer: BCBS Trust/PPO	$29.06
Rate for Payer: Cash Price	$299.20
Rate for Payer: Cash Price	$299.20
Rate for Payer: Meridian Medicaid	$123.90
Rate for Payer: Priority Health Choice Medicaid	$118.00
Rate for Payer: Priority Health Cigna Priority Health	$261.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$323.98
Rate for Payer: Priority Health Narrow Network	$323.98
Rate for Payer: Priority Health SBD	$323.98
Rate for Payer: UMR Bronson Commercial	$172.04

PR ESOPHAGOSCOPY RIGID TRANSORAL DIAGNOSTIC BRUSH

Professional

Both

$394.00

Service Code	HCPCS 43191
Min. Negotiated Rate	$63.92
Max. Negotiated Rate	$275.80
Rate for Payer: Aetna Commercial	$204.70
Rate for Payer: BCBS Complete	$104.22
Rate for Payer: BCBS Trust/PPO	$63.92
Rate for Payer: Cash Price	$315.20
Rate for Payer: Cash Price	$315.20
Rate for Payer: Meridian Medicaid	$104.22
Rate for Payer: Priority Health Choice Medicaid	$99.26
Rate for Payer: Priority Health Cigna Priority Health	$275.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$272.24
Rate for Payer: Priority Health Narrow Network	$272.24
Rate for Payer: Priority Health SBD	$272.24
Rate for Payer: UMR Bronson Commercial	$181.24

PR ESOPHAGOSCOPY RIGID TRANSORAL INJ SUBMUCOSAL

Professional

Both

$337.00

Service Code	HCPCS 43192
Min. Negotiated Rate	$77.66
Max. Negotiated Rate	$297.52
Rate for Payer: Aetna Commercial	$224.57
Rate for Payer: BCBS Complete	$113.84
Rate for Payer: BCBS Trust/PPO	$77.66
Rate for Payer: Cash Price	$269.60
Rate for Payer: Cash Price	$269.60
Rate for Payer: Meridian Medicaid	$113.84
Rate for Payer: Priority Health Choice Medicaid	$108.42
Rate for Payer: Priority Health Cigna Priority Health	$235.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$297.52
Rate for Payer: Priority Health Narrow Network	$297.52
Rate for Payer: Priority Health SBD	$297.52
Rate for Payer: UMR Bronson Commercial	$155.02

PR ESOPHAGOSCOPY RIGID TRANSORAL WITH BIOPSY

Professional

Both

$521.00

Service Code	HCPCS 43193
Min. Negotiated Rate	$46.49
Max. Negotiated Rate	$364.70
Rate for Payer: Aetna Commercial	$223.22
Rate for Payer: BCBS Complete	$113.39
Rate for Payer: BCBS Trust/PPO	$46.49
Rate for Payer: Cash Price	$416.80
Rate for Payer: Cash Price	$416.80
Rate for Payer: Meridian Medicaid	$113.39
Rate for Payer: Priority Health Choice Medicaid	$107.99
Rate for Payer: Priority Health Cigna Priority Health	$364.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$296.34
Rate for Payer: Priority Health Narrow Network	$296.34
Rate for Payer: Priority Health SBD	$296.34
Rate for Payer: UMR Bronson Commercial	$239.66

PR ESOPHAGOSCOPY RIG TRANSORAL REMOVAL FOREIGN BODY

Professional

Both

$472.00

Service Code	HCPCS 43194
Min. Negotiated Rate	$54.94
Max. Negotiated Rate	$336.31
Rate for Payer: Aetna Commercial	$256.30
Rate for Payer: BCBS Complete	$127.03
Rate for Payer: BCBS Trust/PPO	$54.94
Rate for Payer: Cash Price	$377.60
Rate for Payer: Cash Price	$377.60
Rate for Payer: Meridian Medicaid	$127.03
Rate for Payer: Priority Health Choice Medicaid	$120.98
Rate for Payer: Priority Health Cigna Priority Health	$330.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$336.31
Rate for Payer: Priority Health Narrow Network	$336.31
Rate for Payer: Priority Health SBD	$336.31
Rate for Payer: UMR Bronson Commercial	$217.12

PR ESOPHAGOSCOPY TRANSORAL STENT PLACEMENT

Professional

Both

$563.00

Service Code	HCPCS 43212
Min. Negotiated Rate	$118.85
Max. Negotiated Rate	$394.10
Rate for Payer: Aetna Commercial	$253.36
Rate for Payer: BCBS Complete	$124.79
Rate for Payer: BCBS Trust/PPO	$156.91
Rate for Payer: Cash Price	$450.40
Rate for Payer: Cash Price	$450.40
Rate for Payer: Meridian Medicaid	$124.79
Rate for Payer: Priority Health Choice Medicaid	$118.85
Rate for Payer: Priority Health Cigna Priority Health	$394.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$328.09
Rate for Payer: Priority Health Narrow Network	$328.09
Rate for Payer: Priority Health SBD	$328.09
Rate for Payer: UMR Bronson Commercial	$258.98

PR ESOPHAGOSCP RIG TRANSORAL HYPOPHARYNX CRV ESOPH

Professional

Both

$1,296.00

Service Code	HCPCS 43180
Min. Negotiated Rate	$66.57
Max. Negotiated Rate	$962.51
Rate for Payer: Aetna Commercial	$724.74
Rate for Payer: BCBS Complete	$367.91
Rate for Payer: BCBS Trust/PPO	$66.57
Rate for Payer: Cash Price	$1,036.80
Rate for Payer: Cash Price	$1,036.80
Rate for Payer: Meridian Medicaid	$367.91
Rate for Payer: Priority Health Choice Medicaid	$350.39
Rate for Payer: Priority Health Cigna Priority Health	$907.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$962.51
Rate for Payer: Priority Health Narrow Network	$962.51
Rate for Payer: Priority Health SBD	$962.51
Rate for Payer: UMR Bronson Commercial	$596.16

PR ESOPHAGOSTOMY FSTLJ ESOPH XTRNL CRV APPR

Professional

Both

$2,342.00

Service Code	HCPCS 43352
Min. Negotiated Rate	$676.91
Max. Negotiated Rate	$1,857.41
Rate for Payer: Aetna Commercial	$1,431.41
Rate for Payer: BCBS Complete	$710.76
Rate for Payer: BCBS Trust/PPO	$1,158.75
Rate for Payer: Cash Price	$1,873.60
Rate for Payer: Cash Price	$1,873.60
Rate for Payer: Meridian Medicaid	$710.76
Rate for Payer: Priority Health Choice Medicaid	$676.91
Rate for Payer: Priority Health Cigna Priority Health	$1,639.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,857.41
Rate for Payer: Priority Health Narrow Network	$1,857.41
Rate for Payer: Priority Health SBD	$1,857.41
Rate for Payer: UMR Bronson Commercial	$1,077.32

PR ESOPHAGOSTOMY FSTLJ ESOPH XTRNL THRC APPR

Professional

Both

$3,468.00

Service Code	HCPCS 43351
Min. Negotiated Rate	$836.45
Max. Negotiated Rate	$2,427.60
Rate for Payer: Aetna Commercial	$1,767.68
Rate for Payer: BCBS Complete	$878.27
Rate for Payer: BCBS Trust/PPO	$1,088.94
Rate for Payer: Cash Price	$2,774.40
Rate for Payer: Cash Price	$2,774.40
Rate for Payer: Meridian Medicaid	$878.27
Rate for Payer: Priority Health Choice Medicaid	$836.45
Rate for Payer: Priority Health Cigna Priority Health	$2,427.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,292.50
Rate for Payer: Priority Health Narrow Network	$2,292.50
Rate for Payer: Priority Health SBD	$2,292.50
Rate for Payer: UMR Bronson Commercial	$1,595.28

PR ESOPHAGOTOMY THORACIC APPR W/RMVL FB

Professional

Both

$3,212.00

Service Code	HCPCS 43045
Min. Negotiated Rate	$272.07
Max. Negotiated Rate	$2,266.63
Rate for Payer: Aetna Commercial	$1,746.60
Rate for Payer: BCBS Complete	$867.76
Rate for Payer: BCBS Trust/PPO	$272.07
Rate for Payer: Cash Price	$2,569.60
Rate for Payer: Cash Price	$2,569.60
Rate for Payer: Meridian Medicaid	$867.76
Rate for Payer: Priority Health Choice Medicaid	$826.44
Rate for Payer: Priority Health Cigna Priority Health	$2,248.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,266.63
Rate for Payer: Priority Health Narrow Network	$2,266.63
Rate for Payer: Priority Health SBD	$2,266.63
Rate for Payer: UMR Bronson Commercial	$1,477.52

PR ESOPHGL FUNCJ G-ESOP RFLX IMPD ELTRD PROLNG

Professional

Both

$111.00

Service Code	HCPCS 91038
Min. Negotiated Rate	$44.40
Max. Negotiated Rate	$932.98
Rate for Payer: Aetna Commercial	$474.97
Rate for Payer: Aetna Commercial	$474.97
Rate for Payer: BCBS Complete	$321.20
Rate for Payer: BCBS Complete	$44.40
Rate for Payer: BCBS Trust/PPO	$932.98
Rate for Payer: BCBS Trust/PPO	$932.98
Rate for Payer: Cash Price	$642.40
Rate for Payer: Cash Price	$88.80
Rate for Payer: Cash Price	$642.40
Rate for Payer: Cash Price	$88.80
Rate for Payer: Priority Health Cigna Priority Health	$77.70
Rate for Payer: Priority Health Cigna Priority Health	$562.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$72.76
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$72.76
Rate for Payer: Priority Health Narrow Network	$72.76
Rate for Payer: Priority Health Narrow Network	$72.76
Rate for Payer: Priority Health SBD	$550.65
Rate for Payer: Priority Health SBD	$550.65
Rate for Payer: UMR Bronson Commercial	$369.38
Rate for Payer: UMR Bronson Commercial	$51.06

PR ESPHAGOSCOPY FLEX LESION REMOVAL HOT BX FORCEPS

Professional

Both

$1,147.00

Service Code	HCPCS 43216
Min. Negotiated Rate	$84.14
Max. Negotiated Rate	$802.90
Rate for Payer: Aetna Commercial	$177.41
Rate for Payer: BCBS Complete	$88.35
Rate for Payer: BCBS Trust/PPO	$137.36
Rate for Payer: Cash Price	$917.60
Rate for Payer: Cash Price	$917.60
Rate for Payer: Meridian Medicaid	$88.35
Rate for Payer: Priority Health Choice Medicaid	$84.14
Rate for Payer: Priority Health Cigna Priority Health	$802.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$229.90
Rate for Payer: Priority Health Narrow Network	$229.90
Rate for Payer: Priority Health SBD	$229.90
Rate for Payer: UMR Bronson Commercial	$527.62

PR ESPHGOSCOPY FLEX W/BAND LIGATION ESOPHGL VARICES

Professional

Both

$1,082.00

Service Code	HCPCS 43205
Min. Negotiated Rate	$88.82
Max. Negotiated Rate	$757.40
Rate for Payer: Aetna Commercial	$187.01
Rate for Payer: BCBS Complete	$93.26
Rate for Payer: BCBS Trust/PPO	$278.94
Rate for Payer: Cash Price	$865.60
Rate for Payer: Cash Price	$865.60
Rate for Payer: Meridian Medicaid	$93.26
Rate for Payer: Priority Health Choice Medicaid	$88.82
Rate for Payer: Priority Health Cigna Priority Health	$757.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$242.83
Rate for Payer: Priority Health Narrow Network	$242.83
Rate for Payer: Priority Health SBD	$242.83
Rate for Payer: UMR Bronson Commercial	$497.72

PR ESPHGP CGEN DFCT THRC APPR W/O RPR FSTL

Professional

Both

$6,527.00

Service Code	HCPCS 43313
Min. Negotiated Rate	$1,290.11
Max. Negotiated Rate	$5,080.67
Rate for Payer: Aetna Commercial	$3,673.09
Rate for Payer: BCBS Complete	$1,943.97
Rate for Payer: BCBS Trust/PPO	$1,290.11
Rate for Payer: Cash Price	$5,221.60
Rate for Payer: Cash Price	$5,221.60
Rate for Payer: Meridian Medicaid	$1,943.97
Rate for Payer: Priority Health Choice Medicaid	$1,851.40
Rate for Payer: Priority Health Cigna Priority Health	$4,568.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$5,080.67
Rate for Payer: Priority Health Narrow Network	$5,080.67
Rate for Payer: Priority Health SBD	$5,080.67
Rate for Payer: UMR Bronson Commercial	$3,002.42

PR ESPHGP CGEN DFCT THRC APPR W/RPR FSTL

Professional

Both

$7,419.00

Service Code	HCPCS 43314
Min. Negotiated Rate	$1,288.00
Max. Negotiated Rate	$5,444.62
Rate for Payer: Aetna Commercial	$3,959.46
Rate for Payer: BCBS Complete	$2,079.72
Rate for Payer: BCBS Trust/PPO	$1,288.00
Rate for Payer: Cash Price	$5,935.20
Rate for Payer: Cash Price	$5,935.20
Rate for Payer: Meridian Medicaid	$2,079.72
Rate for Payer: Priority Health Choice Medicaid	$1,980.69
Rate for Payer: Priority Health Cigna Priority Health	$5,193.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$5,444.62
Rate for Payer: Priority Health Narrow Network	$5,444.62
Rate for Payer: Priority Health SBD	$5,444.62
Rate for Payer: UMR Bronson Commercial	$3,412.74

PR ESPHGP CRV APPR W/O RPR TRACHEOESOPHGL FSTL

Professional

Both

$2,031.00

Service Code	HCPCS 43300
Min. Negotiated Rate	$403.64
Max. Negotiated Rate	$1,573.28
Rate for Payer: Aetna Commercial	$820.41
Rate for Payer: BCBS Complete	$423.82
Rate for Payer: BCBS Trust/PPO	$1,573.28
Rate for Payer: Cash Price	$1,624.80
Rate for Payer: Cash Price	$1,624.80
Rate for Payer: Meridian Medicaid	$423.82
Rate for Payer: Priority Health Choice Medicaid	$403.64
Rate for Payer: Priority Health Cigna Priority Health	$1,421.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,106.57
Rate for Payer: Priority Health Narrow Network	$1,106.57
Rate for Payer: Priority Health SBD	$1,106.57
Rate for Payer: UMR Bronson Commercial	$934.26

PR ESPHGP THRC APPR W/O RPR TRACHEOESOPHGL FSTL

Professional

Both

$4,879.00

Service Code	HCPCS 43310
Min. Negotiated Rate	$934.86
Max. Negotiated Rate	$3,415.30
Rate for Payer: Aetna Commercial	$1,993.99
Rate for Payer: BCBS Complete	$981.60
Rate for Payer: BCBS Trust/PPO	$1,024.37
Rate for Payer: Cash Price	$3,903.20
Rate for Payer: Cash Price	$3,903.20
Rate for Payer: Meridian Medicaid	$981.60
Rate for Payer: Priority Health Choice Medicaid	$934.86
Rate for Payer: Priority Health Cigna Priority Health	$3,415.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,569.44
Rate for Payer: Priority Health Narrow Network	$2,569.44
Rate for Payer: Priority Health SBD	$2,569.44
Rate for Payer: UMR Bronson Commercial	$2,244.34

PR ESPHGP THRC APPR W/RPR TRACHEOESOPHGL FSTL

Professional

Both

$3,288.00

Service Code	HCPCS 43312
Min. Negotiated Rate	$998.12
Max. Negotiated Rate	$2,744.65
Rate for Payer: Aetna Commercial	$2,140.84
Rate for Payer: BCBS Complete	$1,048.03
Rate for Payer: BCBS Trust/PPO	$1,130.03
Rate for Payer: Cash Price	$2,630.40
Rate for Payer: Cash Price	$2,630.40
Rate for Payer: Meridian Medicaid	$1,048.03
Rate for Payer: Priority Health Choice Medicaid	$998.12
Rate for Payer: Priority Health Cigna Priority Health	$2,301.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,744.65
Rate for Payer: Priority Health Narrow Network	$2,744.65
Rate for Payer: Priority Health SBD	$2,744.65
Rate for Payer: UMR Bronson Commercial	$1,512.48

PR ESRD RELATED SVC <FULL MONTH 20/>YR OLD

Professional

Both

$14.00

Service Code	HCPCS 90970
Min. Negotiated Rate	$5.96
Max. Negotiated Rate	$77.13
Rate for Payer: Aetna Commercial	$10.62
Rate for Payer: BCBS Complete	$6.26
Rate for Payer: BCBS Trust/PPO	$77.13
Rate for Payer: Cash Price	$11.20
Rate for Payer: Cash Price	$11.20
Rate for Payer: Meridian Medicaid	$6.26
Rate for Payer: Priority Health Choice Medicaid	$5.96
Rate for Payer: Priority Health Cigna Priority Health	$9.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$12.58
Rate for Payer: Priority Health Narrow Network	$12.58
Rate for Payer: Priority Health SBD	$12.58
Rate for Payer: UMR Bronson Commercial	$6.44

PR ESRD RELATED SVC MONTHLY 20&/>YR OLD 1 VISIT

Professional

Both

$314.00

Service Code	HCPCS 90962
Min. Negotiated Rate	$128.23
Max. Negotiated Rate	$267.69
Rate for Payer: Aetna Commercial	$222.67
Rate for Payer: BCBS Complete	$134.64
Rate for Payer: BCBS Trust/PPO	$136.83
Rate for Payer: Cash Price	$251.20
Rate for Payer: Cash Price	$251.20
Rate for Payer: Meridian Medicaid	$134.64
Rate for Payer: Priority Health Choice Medicaid	$128.23
Rate for Payer: Priority Health Cigna Priority Health	$219.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$267.69
Rate for Payer: Priority Health Narrow Network	$267.69
Rate for Payer: Priority Health SBD	$267.69
Rate for Payer: UMR Bronson Commercial	$144.44

PR ESRD RELATED SVC MONTHLY 20/>YR OLD 2/3 VISITS

Professional

Both

$406.00

Service Code	HCPCS 90961
Min. Negotiated Rate	$103.02
Max. Negotiated Rate	$388.95
Rate for Payer: Aetna Commercial	$326.25
Rate for Payer: BCBS Complete	$195.03
Rate for Payer: BCBS Trust/PPO	$103.02
Rate for Payer: Cash Price	$324.80
Rate for Payer: Cash Price	$324.80
Rate for Payer: Meridian Medicaid	$195.03
Rate for Payer: Priority Health Choice Medicaid	$185.74
Rate for Payer: Priority Health Cigna Priority Health	$284.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$388.95
Rate for Payer: Priority Health Narrow Network	$388.95
Rate for Payer: Priority Health SBD	$388.95
Rate for Payer: UMR Bronson Commercial	$186.76

Know your out-of-pocket cost for care.

All Charges