Bronson Methodist Hospital

All Charges

Charge

Type

Setting

Price

PR ESRD RELATED SVC MONTHLY 20&/> YR OLD 4/> VISITS

Professional

Both

$482.00

Service Code	HCPCS 90960
Min. Negotiated Rate	$221.72
Max. Negotiated Rate	$467.56
Rate for Payer: Aetna Commercial	$394.57
Rate for Payer: BCBS Complete	$234.83
Rate for Payer: BCBS Trust/PPO	$226.11
Rate for Payer: Cash Price	$385.60
Rate for Payer: Cash Price	$385.60
Rate for Payer: Meridian Medicaid	$234.83
Rate for Payer: Priority Health Choice Medicaid	$223.65
Rate for Payer: Priority Health Cigna Priority Health	$337.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$467.56
Rate for Payer: Priority Health Narrow Network	$467.56
Rate for Payer: Priority Health SBD	$467.56
Rate for Payer: UMR Bronson Commercial	$221.72

PR ESRD SVC HOME DIALYSIS FULL MONTH 20 YR OLD

Professional

Both

$417.00

Service Code	HCPCS 90966
Min. Negotiated Rate	$185.74
Max. Negotiated Rate	$388.50
Rate for Payer: Aetna Commercial	$325.90
Rate for Payer: BCBS Complete	$195.03
Rate for Payer: BCBS Trust/PPO	$211.32
Rate for Payer: Cash Price	$333.60
Rate for Payer: Cash Price	$333.60
Rate for Payer: Meridian Medicaid	$195.03
Rate for Payer: Priority Health Choice Medicaid	$185.74
Rate for Payer: Priority Health Cigna Priority Health	$291.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$388.50
Rate for Payer: Priority Health Narrow Network	$388.50
Rate for Payer: Priority Health SBD	$388.50
Rate for Payer: UMR Bronson Commercial	$191.82

PR ESW BY PHYS W/ANES INVG LAT HUMERL EPICONDYLE

Professional

Both

$2,603.00

Service Code	HCPCS 0102T
Min. Negotiated Rate	$132.14
Max. Negotiated Rate	$1,822.10
Rate for Payer: Aetna Commercial	$391.44
Rate for Payer: BCBS Complete	$1,041.20
Rate for Payer: BCBS Trust/PPO	$132.14
Rate for Payer: Cash Price	$2,082.40
Rate for Payer: Cash Price	$2,082.40
Rate for Payer: Priority Health Cigna Priority Health	$1,822.10
Rate for Payer: UMR Bronson Commercial	$1,197.38

PR ETHMOIDECTOMY INTRANASAL ANTERIOR

Professional

Both

$2,500.00

Service Code	HCPCS 31200
Min. Negotiated Rate	$402.57
Max. Negotiated Rate	$1,750.00
Rate for Payer: Aetna Commercial	$785.39
Rate for Payer: BCBS Complete	$422.70
Rate for Payer: BCBS Trust/PPO	$1,062.94
Rate for Payer: Cash Price	$2,000.00
Rate for Payer: Cash Price	$2,000.00
Rate for Payer: Meridian Medicaid	$422.70
Rate for Payer: Priority Health Choice Medicaid	$402.57
Rate for Payer: Priority Health Cigna Priority Health	$1,750.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$871.92
Rate for Payer: Priority Health Narrow Network	$871.92
Rate for Payer: Priority Health SBD	$871.92
Rate for Payer: UMR Bronson Commercial	$1,150.00

PR ETHMOIDECTOMY INTRANASAL TOTAL

Professional

Both

$1,504.00

Service Code	HCPCS 31201
Min. Negotiated Rate	$501.62
Max. Negotiated Rate	$1,116.87
Rate for Payer: Aetna Commercial	$1,010.10
Rate for Payer: BCBS Complete	$526.70
Rate for Payer: BCBS Trust/PPO	$1,073.51
Rate for Payer: Cash Price	$1,203.20
Rate for Payer: Cash Price	$1,203.20
Rate for Payer: Meridian Medicaid	$526.70
Rate for Payer: Priority Health Choice Medicaid	$501.62
Rate for Payer: Priority Health Cigna Priority Health	$1,052.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,116.87
Rate for Payer: Priority Health Narrow Network	$1,116.87
Rate for Payer: Priority Health SBD	$1,116.87
Rate for Payer: UMR Bronson Commercial	$691.84

PR EVACUATION SUBUNGUAL HEMATOMA

Professional

Both

$80.00

Service Code	HCPCS 11740
Min. Negotiated Rate	$20.66
Max. Negotiated Rate	$116.11
Rate for Payer: Aetna Commercial	$31.68
Rate for Payer: BCBS Complete	$21.69
Rate for Payer: BCBS Trust/PPO	$116.11
Rate for Payer: Cash Price	$64.00
Rate for Payer: Cash Price	$64.00
Rate for Payer: Meridian Medicaid	$21.69
Rate for Payer: Priority Health Choice Medicaid	$20.66
Rate for Payer: Priority Health Cigna Priority Health	$56.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$39.05
Rate for Payer: Priority Health Narrow Network	$39.05
Rate for Payer: Priority Health SBD	$39.05
Rate for Payer: UMR Bronson Commercial	$36.80

PR EVAL CENTRAL AUDITORY FUNCJ W/REPRT 1ST 60 MIN

Professional

Both

$165.00

Service Code	HCPCS 92620
Min. Negotiated Rate	$66.00
Max. Negotiated Rate	$295.85
Rate for Payer: Aetna Commercial	$88.66
Rate for Payer: BCBS Complete	$66.00
Rate for Payer: BCBS Trust/PPO	$295.85
Rate for Payer: Cash Price	$132.00
Rate for Payer: Cash Price	$132.00
Rate for Payer: Priority Health Cigna Priority Health	$115.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$105.54
Rate for Payer: Priority Health Narrow Network	$105.54
Rate for Payer: Priority Health SBD	$105.54
Rate for Payer: UMR Bronson Commercial	$75.90

PR EVAL CENTRAL AUDITORY FUNCJ W/REPRT EA 15 MIN

Professional

Both

$39.00

Service Code	HCPCS 92621
Min. Negotiated Rate	$15.60
Max. Negotiated Rate	$281.58
Rate for Payer: Aetna Commercial	$20.83
Rate for Payer: BCBS Complete	$15.60
Rate for Payer: BCBS Trust/PPO	$281.58
Rate for Payer: Cash Price	$31.20
Rate for Payer: Cash Price	$31.20
Rate for Payer: Priority Health Cigna Priority Health	$27.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$24.71
Rate for Payer: Priority Health Narrow Network	$24.71
Rate for Payer: Priority Health SBD	$24.71
Rate for Payer: UMR Bronson Commercial	$17.94

PR EVAL OF ORTHOTIC/PROSTH USE, EA 15 MIN

Professional

Both

$74.00

Service Code	HCPCS 97762
Min. Negotiated Rate	$29.60
Max. Negotiated Rate	$51.80
Rate for Payer: BCBS Complete	$29.60
Rate for Payer: Cash Price	$59.20
Rate for Payer: Priority Health Cigna Priority Health	$51.80
Rate for Payer: UMR Bronson Commercial	$34.04

PR EVAL SPEECH SOUND PRODUCT LANGUAGE COMPREHENSION

Professional

Both

$350.00

Service Code	HCPCS 92523
Min. Negotiated Rate	$140.00
Max. Negotiated Rate	$1,440.15
Rate for Payer: Aetna Commercial	$210.67
Rate for Payer: BCBS Complete	$140.00
Rate for Payer: BCBS Trust/PPO	$1,440.15
Rate for Payer: Cash Price	$280.00
Rate for Payer: Cash Price	$280.00
Rate for Payer: Priority Health Cigna Priority Health	$245.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$304.96
Rate for Payer: Priority Health Narrow Network	$304.96
Rate for Payer: Priority Health SBD	$304.96
Rate for Payer: UMR Bronson Commercial	$161.00

PR EVALUATION OF SPEECH FLUENCY (STUTTER CLUTTER)

Professional

Both

$207.00

Service Code	HCPCS 92521
Min. Negotiated Rate	$82.80
Max. Negotiated Rate	$1,170.71
Rate for Payer: Aetna Commercial	$122.55
Rate for Payer: BCBS Complete	$82.80
Rate for Payer: BCBS Trust/PPO	$1,170.71
Rate for Payer: Cash Price	$165.60
Rate for Payer: Cash Price	$165.60
Rate for Payer: Priority Health Cigna Priority Health	$144.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$177.86
Rate for Payer: Priority Health Narrow Network	$177.86
Rate for Payer: Priority Health SBD	$177.86
Rate for Payer: UMR Bronson Commercial	$95.22

PR EVALUATION OF SPEECH SOUND PRODUCTION ARTICULATE

Professional

Both

$168.00

Service Code	HCPCS 92522
Min. Negotiated Rate	$67.20
Max. Negotiated Rate	$1,580.15
Rate for Payer: Aetna Commercial	$102.73
Rate for Payer: BCBS Complete	$67.20
Rate for Payer: BCBS Trust/PPO	$1,580.15
Rate for Payer: Cash Price	$134.40
Rate for Payer: Cash Price	$134.40
Rate for Payer: Priority Health Cigna Priority Health	$117.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$148.67
Rate for Payer: Priority Health Narrow Network	$148.67
Rate for Payer: Priority Health SBD	$148.67
Rate for Payer: UMR Bronson Commercial	$77.28

PR EVASC INTRACRANIAL PROLNG ADMN RX AGENT ART 1ST

Professional

Both

$1,083.00

Service Code	HCPCS 61650
Min. Negotiated Rate	$318.04
Max. Negotiated Rate	$964.28
Rate for Payer: Aetna Commercial	$737.29
Rate for Payer: BCBS Complete	$389.60
Rate for Payer: BCBS Trust/PPO	$318.04
Rate for Payer: Cash Price	$866.40
Rate for Payer: Cash Price	$866.40
Rate for Payer: Meridian Medicaid	$389.60
Rate for Payer: Priority Health Choice Medicaid	$371.05
Rate for Payer: Priority Health Cigna Priority Health	$758.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$964.28
Rate for Payer: Priority Health Narrow Network	$964.28
Rate for Payer: Priority Health SBD	$964.28
Rate for Payer: UMR Bronson Commercial	$498.18

PR EVASC INTRACRANIAL PROLNG ADMN RX AGENT ART ADDL

Professional

Both

$461.00

Service Code	HCPCS 61651
Min. Negotiated Rate	$158.47
Max. Negotiated Rate	$415.04
Rate for Payer: Aetna Commercial	$316.17
Rate for Payer: BCBS Complete	$166.39
Rate for Payer: BCBS Trust/PPO	$301.13
Rate for Payer: Cash Price	$368.80
Rate for Payer: Cash Price	$368.80
Rate for Payer: Meridian Medicaid	$166.39
Rate for Payer: Priority Health Choice Medicaid	$158.47
Rate for Payer: Priority Health Cigna Priority Health	$322.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$415.04
Rate for Payer: Priority Health Narrow Network	$415.04
Rate for Payer: Priority Health SBD	$415.04
Rate for Payer: UMR Bronson Commercial	$212.06

PR EVASC PLACEMENT ILIAC ARTERY OCCLUSION DEVICE

Professional

Both

$436.00

Service Code	HCPCS 34808
Min. Negotiated Rate	$125.88
Max. Negotiated Rate	$313.33
Rate for Payer: Aetna Commercial	$268.94
Rate for Payer: BCBS Complete	$132.17
Rate for Payer: BCBS Trust/PPO	$212.38
Rate for Payer: Cash Price	$348.80
Rate for Payer: Cash Price	$348.80
Rate for Payer: Meridian Medicaid	$132.17
Rate for Payer: Priority Health Choice Medicaid	$125.88
Rate for Payer: Priority Health Cigna Priority Health	$305.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$313.33
Rate for Payer: Priority Health Narrow Network	$313.33
Rate for Payer: Priority Health SBD	$313.33
Rate for Payer: UMR Bronson Commercial	$200.56

PR EVASC RPR DPLMNT AORTO-AORTIC NDGFT

Professional

Both

$2,537.00

Service Code	HCPCS 34701
Min. Negotiated Rate	$769.14
Max. Negotiated Rate	$1,919.30
Rate for Payer: Aetna Commercial	$1,668.21
Rate for Payer: BCBS Complete	$807.60
Rate for Payer: BCBS Trust/PPO	$1,422.71
Rate for Payer: Cash Price	$2,029.60
Rate for Payer: Cash Price	$2,029.60
Rate for Payer: Meridian Medicaid	$807.60
Rate for Payer: Priority Health Choice Medicaid	$769.14
Rate for Payer: Priority Health Cigna Priority Health	$1,775.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,919.30
Rate for Payer: Priority Health Narrow Network	$1,919.30
Rate for Payer: Priority Health SBD	$1,919.30
Rate for Payer: UMR Bronson Commercial	$1,167.02

PR EVASC RPR DPLMNT AORTO-AORTIC NDGFT RPT

Professional

Both

$3,836.00

Service Code	HCPCS 34702
Min. Negotiated Rate	$1,148.71
Max. Negotiated Rate	$2,863.53
Rate for Payer: Aetna Commercial	$2,491.29
Rate for Payer: BCBS Complete	$1,206.15
Rate for Payer: BCBS Trust/PPO	$2,005.96
Rate for Payer: Cash Price	$3,068.80
Rate for Payer: Cash Price	$3,068.80
Rate for Payer: Meridian Medicaid	$1,206.15
Rate for Payer: Priority Health Choice Medicaid	$1,148.71
Rate for Payer: Priority Health Cigna Priority Health	$2,685.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,863.53
Rate for Payer: Priority Health Narrow Network	$2,863.53
Rate for Payer: Priority Health SBD	$2,863.53
Rate for Payer: UMR Bronson Commercial	$1,764.56

PR EVASC RPR DPLMNT AORTO-BI-ILIAC NDGFT

Professional

Both

$3,104.00

Service Code	HCPCS 34705
Min. Negotiated Rate	$949.98
Max. Negotiated Rate	$2,747.37
Rate for Payer: Aetna Commercial	$2,056.06
Rate for Payer: BCBS Complete	$997.48
Rate for Payer: BCBS Trust/PPO	$2,747.37
Rate for Payer: Cash Price	$2,483.20
Rate for Payer: Cash Price	$2,483.20
Rate for Payer: Meridian Medicaid	$997.48
Rate for Payer: Priority Health Choice Medicaid	$949.98
Rate for Payer: Priority Health Cigna Priority Health	$2,172.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,367.21
Rate for Payer: Priority Health Narrow Network	$2,367.21
Rate for Payer: Priority Health SBD	$2,367.21
Rate for Payer: UMR Bronson Commercial	$1,427.84

PR EVASC RPR DPLMNT AORTO-BI-ILIAC NDGFT RPT

Professional

Both

$4,745.00

Service Code	HCPCS 34706
Min. Negotiated Rate	$1,415.81
Max. Negotiated Rate	$3,526.88
Rate for Payer: Aetna Commercial	$3,096.26
Rate for Payer: BCBS Complete	$1,486.60
Rate for Payer: BCBS Trust/PPO	$2,686.93
Rate for Payer: Cash Price	$3,796.00
Rate for Payer: Cash Price	$3,796.00
Rate for Payer: Meridian Medicaid	$1,486.60
Rate for Payer: Priority Health Choice Medicaid	$1,415.81
Rate for Payer: Priority Health Cigna Priority Health	$3,321.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$3,526.88
Rate for Payer: Priority Health Narrow Network	$3,526.88
Rate for Payer: Priority Health SBD	$3,526.88
Rate for Payer: UMR Bronson Commercial	$2,182.70

PR EVASC RPR DPLMNT AORTO-UN-ILIAC NDGFT

Professional

Both

$2,860.00

Service Code	HCPCS 34703
Min. Negotiated Rate	$854.34
Max. Negotiated Rate	$2,308.14
Rate for Payer: Aetna Commercial	$1,848.30
Rate for Payer: BCBS Complete	$897.06
Rate for Payer: BCBS Trust/PPO	$2,308.14
Rate for Payer: Cash Price	$2,288.00
Rate for Payer: Cash Price	$2,288.00
Rate for Payer: Meridian Medicaid	$897.06
Rate for Payer: Priority Health Choice Medicaid	$854.34
Rate for Payer: Priority Health Cigna Priority Health	$2,002.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,134.21
Rate for Payer: Priority Health Narrow Network	$2,134.21
Rate for Payer: Priority Health SBD	$2,134.21
Rate for Payer: UMR Bronson Commercial	$1,315.60

PR EVASC RPR DPLMNT ILIO-ILIAC NDGFT

Professional

Both

$2,367.00

Service Code	HCPCS 34707
Min. Negotiated Rate	$722.50
Max. Negotiated Rate	$2,209.35
Rate for Payer: Aetna Commercial	$1,567.17
Rate for Payer: BCBS Complete	$758.62
Rate for Payer: BCBS Trust/PPO	$2,209.35
Rate for Payer: Cash Price	$1,893.60
Rate for Payer: Cash Price	$1,893.60
Rate for Payer: Meridian Medicaid	$758.62
Rate for Payer: Priority Health Choice Medicaid	$722.50
Rate for Payer: Priority Health Cigna Priority Health	$1,656.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,809.72
Rate for Payer: Priority Health Narrow Network	$1,809.72
Rate for Payer: Priority Health SBD	$1,809.72
Rate for Payer: UMR Bronson Commercial	$1,088.82

PR EVASC RPR DPLMNT ILIO-ILIAC NDGFT RPT

Professional

Both

$3,823.00

Service Code	HCPCS 34708
Min. Negotiated Rate	$1,132.52
Max. Negotiated Rate	$2,816.72
Rate for Payer: Aetna Commercial	$2,493.77
Rate for Payer: BCBS Complete	$1,189.15
Rate for Payer: BCBS Trust/PPO	$1,929.88
Rate for Payer: Cash Price	$3,058.40
Rate for Payer: Cash Price	$3,058.40
Rate for Payer: Meridian Medicaid	$1,189.15
Rate for Payer: Priority Health Choice Medicaid	$1,132.52
Rate for Payer: Priority Health Cigna Priority Health	$2,676.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,816.72
Rate for Payer: Priority Health Narrow Network	$2,816.72
Rate for Payer: Priority Health SBD	$2,816.72
Rate for Payer: UMR Bronson Commercial	$1,758.58

PR EVASC RPR DTA COVERAGE ART ORIGIN 1ST ENDOPROSTH

Professional

Both

$8,083.00

Service Code	HCPCS 33880
Min. Negotiated Rate	$649.81
Max. Negotiated Rate	$5,658.10
Rate for Payer: Aetna Commercial	$2,407.28
Rate for Payer: BCBS Complete	$1,168.80
Rate for Payer: BCBS Trust/PPO	$649.81
Rate for Payer: Cash Price	$6,466.40
Rate for Payer: Cash Price	$6,466.40
Rate for Payer: Meridian Medicaid	$1,168.80
Rate for Payer: Priority Health Choice Medicaid	$1,113.14
Rate for Payer: Priority Health Cigna Priority Health	$5,658.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,778.95
Rate for Payer: Priority Health Narrow Network	$2,778.95
Rate for Payer: Priority Health SBD	$2,778.95
Rate for Payer: UMR Bronson Commercial	$3,718.18

PR EVASC RPR DTA EXP COVERAGE W/O ART ORIGIN

Professional

Both

$5,396.00

Service Code	HCPCS 33881
Min. Negotiated Rate	$924.53
Max. Negotiated Rate	$3,777.20
Rate for Payer: Aetna Commercial	$2,063.09
Rate for Payer: BCBS Complete	$1,003.97
Rate for Payer: BCBS Trust/PPO	$924.53
Rate for Payer: Cash Price	$4,316.80
Rate for Payer: Cash Price	$4,316.80
Rate for Payer: Meridian Medicaid	$1,003.97
Rate for Payer: Priority Health Choice Medicaid	$956.16
Rate for Payer: Priority Health Cigna Priority Health	$3,777.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,381.04
Rate for Payer: Priority Health Narrow Network	$2,381.04
Rate for Payer: Priority Health SBD	$2,381.04
Rate for Payer: UMR Bronson Commercial	$2,482.16

PR EVASC RPR ILAC ART BIFUR ENDGRFT CATHJ RS&I UNI

Professional

Both

$940.00

Service Code	HCPCS 0254T
Min. Negotiated Rate	$376.00
Max. Negotiated Rate	$658.00
Rate for Payer: BCBS Complete	$376.00
Rate for Payer: Cash Price	$752.00
Rate for Payer: Priority Health Cigna Priority Health	$658.00
Rate for Payer: UMR Bronson Commercial	$432.40

Know your out-of-pocket cost for care.

All Charges