Bronson Methodist Hospital

All Charges

Charge

Type

Setting

Price

PR FITTING CONTACT LENS FOR MNGT OF KERATOCONUS

Professional

Both

$217.00

Service Code	HCPCS 92072
Min. Negotiated Rate	$58.58
Max. Negotiated Rate	$900.75
Rate for Payer: Aetna Commercial	$104.39
Rate for Payer: BCBS Complete	$61.51
Rate for Payer: BCBS Trust/PPO	$900.75
Rate for Payer: Cash Price	$173.60
Rate for Payer: Cash Price	$173.60
Rate for Payer: Meridian Medicaid	$61.51
Rate for Payer: Priority Health Choice Medicaid	$58.58
Rate for Payer: Priority Health Cigna Priority Health	$151.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$111.61
Rate for Payer: Priority Health Narrow Network	$111.61
Rate for Payer: Priority Health SBD	$111.61
Rate for Payer: UMR Bronson Commercial	$99.82

PR FIXATION CONTRALATERAL TESTIS SEPARATE PROCEDURE

Professional

Both

$563.00

Service Code	HCPCS 54620
Min. Negotiated Rate	$190.21
Max. Negotiated Rate	$3,422.86
Rate for Payer: Aetna Commercial	$383.67
Rate for Payer: BCBS Complete	$199.72
Rate for Payer: BCBS Trust/PPO	$3,422.86
Rate for Payer: Cash Price	$450.40
Rate for Payer: Cash Price	$450.40
Rate for Payer: Meridian Medicaid	$199.72
Rate for Payer: Priority Health Choice Medicaid	$190.21
Rate for Payer: Priority Health Cigna Priority Health	$394.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$477.13
Rate for Payer: Priority Health Narrow Network	$477.13
Rate for Payer: Priority Health SBD	$477.13
Rate for Payer: UMR Bronson Commercial	$258.98

PR FLAP ISLAND PEDICLE ANATOMIC NAMED AXIAL ARTERY

Professional

Both

$1,699.00

Service Code	HCPCS 15740
Min. Negotiated Rate	$538.89
Max. Negotiated Rate	$1,709.25
Rate for Payer: Aetna Commercial	$895.75
Rate for Payer: BCBS Complete	$565.83
Rate for Payer: BCBS Trust/PPO	$1,709.25
Rate for Payer: Cash Price	$1,359.20
Rate for Payer: Cash Price	$1,359.20
Rate for Payer: Meridian Medicaid	$565.83
Rate for Payer: Priority Health Choice Medicaid	$538.89
Rate for Payer: Priority Health Cigna Priority Health	$1,189.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,030.47
Rate for Payer: Priority Health Narrow Network	$1,030.47
Rate for Payer: Priority Health SBD	$1,030.47
Rate for Payer: UMR Bronson Commercial	$781.54

PR FLUORESCEIN ANGIOSCOPY INTERPRETATION & REPORT

Professional

Both

$116.00

Service Code	HCPCS 92230
Min. Negotiated Rate	$21.73
Max. Negotiated Rate	$1,393.66
Rate for Payer: Aetna Commercial	$36.07
Rate for Payer: BCBS Complete	$22.82
Rate for Payer: BCBS Trust/PPO	$1,393.66
Rate for Payer: Cash Price	$92.80
Rate for Payer: Cash Price	$92.80
Rate for Payer: Meridian Medicaid	$22.82
Rate for Payer: Priority Health Choice Medicaid	$21.73
Rate for Payer: Priority Health Cigna Priority Health	$81.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$40.94
Rate for Payer: Priority Health Narrow Network	$40.94
Rate for Payer: Priority Health SBD	$40.94
Rate for Payer: UMR Bronson Commercial	$53.36

PR FLUPHENAZINE DECANOATE 25 MG

Professional

Both

$24.00

Service Code	HCPCS J2680
Min. Negotiated Rate	$5.22
Max. Negotiated Rate	$16.80
Rate for Payer: Aetna Commercial	$9.42
Rate for Payer: BCBS Complete	$9.60
Rate for Payer: BCBS Trust/PPO	$5.22
Rate for Payer: Cash Price	$19.20
Rate for Payer: Cash Price	$19.20
Rate for Payer: Priority Health Cigna Priority Health	$16.80
Rate for Payer: UMR Bronson Commercial	$11.04

PR FLUVIRIN VACC, 3 YRS & >, IM

Professional

Both

$20.00

Service Code	HCPCS Q2037
Min. Negotiated Rate	$8.00
Max. Negotiated Rate	$18.62
Rate for Payer: Aetna Commercial	$18.62
Rate for Payer: BCBS Complete	$8.00
Rate for Payer: BCBS Trust/PPO	$17.00
Rate for Payer: Cash Price	$16.00
Rate for Payer: Cash Price	$16.00
Rate for Payer: Priority Health Cigna Priority Health	$14.00
Rate for Payer: UMR Bronson Commercial	$9.20

PR FLUZONE VACC, 3 YRS & >, IM

Professional

Both

$25.00

Service Code	HCPCS Q2038
Min. Negotiated Rate	$10.00
Max. Negotiated Rate	$17.50
Rate for Payer: Aetna Commercial	$12.68
Rate for Payer: BCBS Complete	$10.00
Rate for Payer: BCBS Trust/PPO	$17.00
Rate for Payer: Cash Price	$20.00
Rate for Payer: Cash Price	$20.00
Rate for Payer: Priority Health Cigna Priority Health	$17.50
Rate for Payer: UMR Bronson Commercial	$11.50

PR FOLLOW-UP/REASSESSMENT

Professional

Both

$300.00

Service Code	HCPCS S0316
Min. Negotiated Rate	$20.00
Max. Negotiated Rate	$210.00
Rate for Payer: Aetna Commercial	$20.00
Rate for Payer: BCBS Complete	$120.00
Rate for Payer: BCBS Trust/PPO	$53.36
Rate for Payer: Cash Price	$240.00
Rate for Payer: Cash Price	$240.00
Rate for Payer: Priority Health Cigna Priority Health	$210.00
Rate for Payer: UMR Bronson Commercial	$138.00

PR FO NONTORSION JOINT CF

Professional

Both

$203.00

Service Code	HCPCS L3935
Min. Negotiated Rate	$81.20
Max. Negotiated Rate	$142.10
Rate for Payer: Aetna Commercial	$121.09
Rate for Payer: BCBS Complete	$81.20
Rate for Payer: Cash Price	$162.40
Rate for Payer: Cash Price	$162.40
Rate for Payer: Priority Health Cigna Priority Health	$142.10
Rate for Payer: UMR Bronson Commercial	$93.38

PR FOOT ARCH SUPP LONGITUD/META

Professional

Both

$40.00

Service Code	HCPCS L3060
Min. Negotiated Rate	$16.00
Max. Negotiated Rate	$44.42
Rate for Payer: Aetna Commercial	$44.42
Rate for Payer: BCBS Complete	$16.00
Rate for Payer: Cash Price	$32.00
Rate for Payer: Cash Price	$32.00
Rate for Payer: Priority Health Cigna Priority Health	$28.00
Rate for Payer: UMR Bronson Commercial	$18.40

PR FOOT PLAS HEEL STABI PRE OTS

Professional

Both

$49.00

Service Code	HCPCS L3170
Min. Negotiated Rate	$19.60
Max. Negotiated Rate	$34.30
Rate for Payer: Aetna Commercial	$30.64
Rate for Payer: BCBS Complete	$19.60
Rate for Payer: Cash Price	$39.20
Rate for Payer: Cash Price	$39.20
Rate for Payer: Priority Health Cigna Priority Health	$34.30
Rate for Payer: UMR Bronson Commercial	$22.54

PR FO PIP DIP JNT/SPRNG PRE OTS

Professional

Both

$61.00

Service Code	HCPCS L3925
Min. Negotiated Rate	$24.40
Max. Negotiated Rate	$42.70
Rate for Payer: Aetna Commercial	$36.01
Rate for Payer: BCBS Complete	$24.40
Rate for Payer: Cash Price	$48.80
Rate for Payer: Cash Price	$48.80
Rate for Payer: Priority Health Cigna Priority Health	$42.70
Rate for Payer: UMR Bronson Commercial	$28.06

PR FOREARM/ARM CUFFS FREE MOTIO

Professional

Both

$625.00

Service Code	HCPCS L3720
Min. Negotiated Rate	$250.00
Max. Negotiated Rate	$437.50
Rate for Payer: Aetna Commercial	$374.53
Rate for Payer: BCBS Complete	$250.00
Rate for Payer: Cash Price	$500.00
Rate for Payer: Cash Price	$500.00
Rate for Payer: Priority Health Cigna Priority Health	$437.50
Rate for Payer: UMR Bronson Commercial	$287.50

PR FOREHEAD FLAP W/PRESERVATION VASCULAR PEDICLE

Professional

Both

$2,215.00

Service Code	HCPCS 15731
Min. Negotiated Rate	$637.30
Max. Negotiated Rate	$1,550.50
Rate for Payer: Aetna Commercial	$1,071.45
Rate for Payer: BCBS Complete	$669.16
Rate for Payer: BCBS Trust/PPO	$852.18
Rate for Payer: Cash Price	$1,772.00
Rate for Payer: Cash Price	$1,772.00
Rate for Payer: Meridian Medicaid	$669.16
Rate for Payer: Priority Health Choice Medicaid	$637.30
Rate for Payer: Priority Health Cigna Priority Health	$1,550.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,223.66
Rate for Payer: Priority Health Narrow Network	$1,223.66
Rate for Payer: Priority Health SBD	$1,223.66
Rate for Payer: UMR Bronson Commercial	$1,018.90

PR FORESKN MANJ W/LSS PREPUTIAL ADS&STRETCHING

Professional

Both

$150.00

Service Code	HCPCS 54450
Min. Negotiated Rate	$36.00
Max. Negotiated Rate	$1,562.18
Rate for Payer: Aetna Commercial	$73.96
Rate for Payer: BCBS Complete	$37.80
Rate for Payer: BCBS Trust/PPO	$1,562.18
Rate for Payer: Cash Price	$120.00
Rate for Payer: Cash Price	$120.00
Rate for Payer: Meridian Medicaid	$37.80
Rate for Payer: Priority Health Choice Medicaid	$36.00
Rate for Payer: Priority Health Cigna Priority Health	$105.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$90.78
Rate for Payer: Priority Health Narrow Network	$90.78
Rate for Payer: Priority Health SBD	$90.78
Rate for Payer: UMR Bronson Commercial	$69.00

PR FO W/O JOINTS CF

Professional

Both

$196.00

Service Code	HCPCS L3933
Min. Negotiated Rate	$78.40
Max. Negotiated Rate	$137.20
Rate for Payer: Aetna Commercial	$116.96
Rate for Payer: BCBS Complete	$78.40
Rate for Payer: Cash Price	$156.80
Rate for Payer: Cash Price	$156.80
Rate for Payer: Priority Health Cigna Priority Health	$137.20
Rate for Payer: UMR Bronson Commercial	$90.16

PR FRAC FL FACE

Professional

Both

$400.00

Service Code	HCPCS 00100
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 FRAC NECK

Professional

Both

$150.00

Service Code	HCPCS 00102
Hospital Revenue Code	990
Min. Negotiated Rate	$60.00
Max. Negotiated Rate	$105.00
Rate for Payer: BCBS Complete	$60.00
Rate for Payer: Cash Price	$120.00
Rate for Payer: Priority Health Cigna Priority Health	$105.00
Rate for Payer: UMR Bronson Commercial	$69.00

PR FRAC SCARS PER INCH

Professional

Both

$50.00

Service Code	HCPCS 00104
Hospital Revenue Code	990
Min. Negotiated Rate	$20.00
Max. Negotiated Rate	$35.00
Rate for Payer: BCBS Complete	$20.00
Rate for Payer: Cash Price	$40.00
Rate for Payer: Priority Health Cigna Priority Health	$35.00
Rate for Payer: UMR Bronson Commercial	$23.00

PR FRAC THGH/ABD/BACK

Professional

Both

$450.00

Service Code	HCPCS 00103
Hospital Revenue Code	990
Min. Negotiated Rate	$180.00
Max. Negotiated Rate	$315.00
Rate for Payer: BCBS Complete	$180.00
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 FRACTURE NASAL INFERIOR TURBINATE THERAPEUTIC

Professional

Both

$522.00

Service Code	HCPCS 30930
Min. Negotiated Rate	$76.47
Max. Negotiated Rate	$790.87
Rate for Payer: Aetna Commercial	$147.55
Rate for Payer: BCBS Complete	$80.29
Rate for Payer: BCBS Trust/PPO	$790.87
Rate for Payer: Cash Price	$417.60
Rate for Payer: Cash Price	$417.60
Rate for Payer: Meridian Medicaid	$80.29
Rate for Payer: Priority Health Choice Medicaid	$76.47
Rate for Payer: Priority Health Cigna Priority Health	$365.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$164.38
Rate for Payer: Priority Health Narrow Network	$164.38
Rate for Payer: Priority Health SBD	$164.38
Rate for Payer: UMR Bronson Commercial	$240.12

PR FRAC UP/LOW FACE

Professional

Both

$250.00

Service Code	HCPCS 00101
Hospital Revenue Code	990
Min. Negotiated Rate	$100.00
Max. Negotiated Rate	$175.00
Rate for Payer: BCBS Complete	$100.00
Rate for Payer: Cash Price	$200.00
Rate for Payer: Priority Health Cigna Priority Health	$175.00
Rate for Payer: UMR Bronson Commercial	$115.00

PR FRENOPLASTY SURG REVJ FRENUM EG W/Z-PLASTY

Professional

Both

$558.00

Service Code	HCPCS 41520
Min. Negotiated Rate	$162.09
Max. Negotiated Rate	$653.51
Rate for Payer: Aetna Commercial	$326.38
Rate for Payer: BCBS Complete	$170.19
Rate for Payer: BCBS Trust/PPO	$653.51
Rate for Payer: Cash Price	$446.40
Rate for Payer: Cash Price	$446.40
Rate for Payer: Meridian Medicaid	$170.19
Rate for Payer: Priority Health Choice Medicaid	$162.09
Rate for Payer: Priority Health Cigna Priority Health	$390.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$445.10
Rate for Payer: Priority Health Narrow Network	$445.10
Rate for Payer: Priority Health SBD	$445.10
Rate for Payer: UMR Bronson Commercial	$256.68

PR FRENULOTOMY PENIS

Professional

Both

$809.00

Service Code	HCPCS 54164
Min. Negotiated Rate	$125.03
Max. Negotiated Rate	$1,012.75
Rate for Payer: Aetna Commercial	$244.64
Rate for Payer: BCBS Complete	$131.28
Rate for Payer: BCBS Trust/PPO	$1,012.75
Rate for Payer: Cash Price	$647.20
Rate for Payer: Cash Price	$647.20
Rate for Payer: Meridian Medicaid	$131.28
Rate for Payer: Priority Health Choice Medicaid	$125.03
Rate for Payer: Priority Health Cigna Priority Health	$566.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$310.70
Rate for Payer: Priority Health Narrow Network	$310.70
Rate for Payer: Priority Health SBD	$310.70
Rate for Payer: UMR Bronson Commercial	$372.14

PR FRMJ DIRECT/TUBED PEDICLE W/WO TRANSFER TRUNK

Professional

Both

$1,474.00

Service Code	HCPCS 15570
Min. Negotiated Rate	$33.96
Max. Negotiated Rate	$1,031.80
Rate for Payer: Aetna Commercial	$788.69
Rate for Payer: BCBS Complete	$489.79
Rate for Payer: BCBS Trust/PPO	$33.96
Rate for Payer: Cash Price	$1,179.20
Rate for Payer: Cash Price	$1,179.20
Rate for Payer: Meridian Medicaid	$489.79
Rate for Payer: Priority Health Choice Medicaid	$466.47
Rate for Payer: Priority Health Cigna Priority Health	$1,031.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$897.30
Rate for Payer: Priority Health Narrow Network	$897.30
Rate for Payer: Priority Health SBD	$897.30
Rate for Payer: UMR Bronson Commercial	$678.04

Know your out-of-pocket cost for care.

All Charges