Bronson Methodist Hospital

All Charges

Charge

Type

Setting

Price

PR GASTROJEJUNOSTOMY W/VAGOTOMY ANY TYPE

Professional

Both

$2,530.00

Service Code	HCPCS 43825
Min. Negotiated Rate	$669.36
Max. Negotiated Rate	$2,304.27
Rate for Payer: Aetna Commercial	$1,773.70
Rate for Payer: BCBS Complete	$880.96
Rate for Payer: BCBS Trust/PPO	$669.36
Rate for Payer: Cash Price	$2,024.00
Rate for Payer: Cash Price	$2,024.00
Rate for Payer: Meridian Medicaid	$880.96
Rate for Payer: Priority Health Choice Medicaid	$839.01
Rate for Payer: Priority Health Cigna Priority Health	$1,771.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,304.27
Rate for Payer: Priority Health Narrow Network	$2,304.27
Rate for Payer: Priority Health SBD	$2,304.27
Rate for Payer: UMR Bronson Commercial	$1,163.80

PR GASTRORRHAPHY SUTR PRF8 DUOL/GSTR ULCER WND/INJ

Professional

Both

$2,766.00

Service Code	HCPCS 43840
Min. Negotiated Rate	$75.56
Max. Negotiated Rate	$2,387.17
Rate for Payer: Aetna Commercial	$1,836.77
Rate for Payer: BCBS Complete	$912.49
Rate for Payer: BCBS Trust/PPO	$75.56
Rate for Payer: Cash Price	$2,212.80
Rate for Payer: Cash Price	$2,212.80
Rate for Payer: Meridian Medicaid	$912.49
Rate for Payer: Priority Health Choice Medicaid	$869.04
Rate for Payer: Priority Health Cigna Priority Health	$1,936.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,387.17
Rate for Payer: Priority Health Narrow Network	$2,387.17
Rate for Payer: Priority Health SBD	$2,387.17
Rate for Payer: UMR Bronson Commercial	$1,272.36

PR GASTROSTOMY OPN NEONATAL FEEDING

Professional

Both

$2,090.00

Service Code	HCPCS 43831
Min. Negotiated Rate	$392.99
Max. Negotiated Rate	$1,463.00
Rate for Payer: Aetna Commercial	$817.73
Rate for Payer: BCBS Complete	$412.64
Rate for Payer: BCBS Trust/PPO	$1,286.41
Rate for Payer: Cash Price	$1,672.00
Rate for Payer: Cash Price	$1,672.00
Rate for Payer: Meridian Medicaid	$412.64
Rate for Payer: Priority Health Choice Medicaid	$392.99
Rate for Payer: Priority Health Cigna Priority Health	$1,463.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,077.75
Rate for Payer: Priority Health Narrow Network	$1,077.75
Rate for Payer: Priority Health SBD	$1,077.75
Rate for Payer: UMR Bronson Commercial	$961.40

PR GASTROSTOMY OPN W/CONSTJ GSTR TUBE

Professional

Both

$2,876.00

Service Code	HCPCS 43832
Min. Negotiated Rate	$670.10
Max. Negotiated Rate	$2,013.20
Rate for Payer: Aetna Commercial	$1,410.13
Rate for Payer: BCBS Complete	$703.60
Rate for Payer: BCBS Trust/PPO	$1,303.84
Rate for Payer: Cash Price	$2,300.80
Rate for Payer: Cash Price	$2,300.80
Rate for Payer: Meridian Medicaid	$703.60
Rate for Payer: Priority Health Choice Medicaid	$670.10
Rate for Payer: Priority Health Cigna Priority Health	$2,013.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,832.70
Rate for Payer: Priority Health Narrow Network	$1,832.70
Rate for Payer: Priority Health SBD	$1,832.70
Rate for Payer: UMR Bronson Commercial	$1,322.96

PR GASTROSTOMY OPN W/O CONSTJ GSTR TUBE SPX

Professional

Both

$2,090.00

Service Code	HCPCS 43830
Min. Negotiated Rate	$281.06
Max. Negotiated Rate	$1,463.00
Rate for Payer: Aetna Commercial	$947.51
Rate for Payer: BCBS Complete	$473.92
Rate for Payer: BCBS Trust/PPO	$281.06
Rate for Payer: Cash Price	$1,672.00
Rate for Payer: Cash Price	$1,672.00
Rate for Payer: Meridian Medicaid	$473.92
Rate for Payer: Priority Health Choice Medicaid	$451.35
Rate for Payer: Priority Health Cigna Priority Health	$1,463.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,239.44
Rate for Payer: Priority Health Narrow Network	$1,239.44
Rate for Payer: Priority Health SBD	$1,239.44
Rate for Payer: UMR Bronson Commercial	$961.40

PR GASTROTOMY W/EXPLORATION/FOREIGN BODY REMOVAL

Professional

Both

$2,212.00

Service Code	HCPCS 43500
Min. Negotiated Rate	$504.38
Max. Negotiated Rate	$1,939.39
Rate for Payer: Aetna Commercial	$1,058.66
Rate for Payer: BCBS Complete	$529.60
Rate for Payer: BCBS Trust/PPO	$1,939.39
Rate for Payer: Cash Price	$1,769.60
Rate for Payer: Cash Price	$1,769.60
Rate for Payer: Meridian Medicaid	$529.60
Rate for Payer: Priority Health Choice Medicaid	$504.38
Rate for Payer: Priority Health Cigna Priority Health	$1,548.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,377.63
Rate for Payer: Priority Health Narrow Network	$1,377.63
Rate for Payer: Priority Health SBD	$1,377.63
Rate for Payer: UMR Bronson Commercial	$1,017.52

PR GASTROTOMY W/SUTURE REPAIR BLEEDING ULCER

Professional

Both

$3,898.00

Service Code	HCPCS 43501
Min. Negotiated Rate	$864.35
Max. Negotiated Rate	$2,728.60
Rate for Payer: Aetna Commercial	$1,821.39
Rate for Payer: BCBS Complete	$907.57
Rate for Payer: BCBS Trust/PPO	$1,062.41
Rate for Payer: Cash Price	$3,118.40
Rate for Payer: Cash Price	$3,118.40
Rate for Payer: Meridian Medicaid	$907.57
Rate for Payer: Priority Health Choice Medicaid	$864.35
Rate for Payer: Priority Health Cigna Priority Health	$2,728.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,363.66
Rate for Payer: Priority Health Narrow Network	$2,363.66
Rate for Payer: Priority Health SBD	$2,363.66
Rate for Payer: UMR Bronson Commercial	$1,793.08

PR GEL-ONE

Professional

Both

$1,340.00

Service Code	HCPCS J7326
Min. Negotiated Rate	$506.67
Max. Negotiated Rate	$938.00
Rate for Payer: Aetna Commercial	$512.21
Rate for Payer: BCBS Complete	$536.00
Rate for Payer: BCBS Trust/PPO	$506.67
Rate for Payer: Cash Price	$1,072.00
Rate for Payer: Cash Price	$1,072.00
Rate for Payer: Priority Health Cigna Priority Health	$938.00
Rate for Payer: UMR Bronson Commercial	$616.40

PR GI TRANSIT & PRES MEAS WIRELESS CAPSULE W/INTERP

Professional

Both

$192.00

Service Code	HCPCS 91112
Min. Negotiated Rate	$76.80
Max. Negotiated Rate	$2,220.11
Rate for Payer: Aetna Commercial	$1,759.47
Rate for Payer: BCBS Complete	$76.80
Rate for Payer: BCBS Trust/PPO	$1,077.20
Rate for Payer: Cash Price	$153.60
Rate for Payer: Cash Price	$153.60
Rate for Payer: Priority Health Cigna Priority Health	$134.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$139.23
Rate for Payer: Priority Health Narrow Network	$139.23
Rate for Payer: Priority Health SBD	$2,220.11
Rate for Payer: UMR Bronson Commercial	$88.32

PR GI TRC IMG INTRALUMINAL ESOPHAGUS-ILEUM W/I&R

Professional

Both

$1,586.00

Service Code	HCPCS 91110
Min. Negotiated Rate	$147.77
Max. Negotiated Rate	$1,110.20
Rate for Payer: Aetna Commercial	$912.51
Rate for Payer: BCBS Complete	$634.40
Rate for Payer: BCBS Trust/PPO	$910.79
Rate for Payer: Cash Price	$1,268.80
Rate for Payer: Cash Price	$1,268.80
Rate for Payer: Priority Health Cigna Priority Health	$1,110.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$147.77
Rate for Payer: Priority Health Narrow Network	$147.77
Rate for Payer: Priority Health SBD	$1,002.93
Rate for Payer: UMR Bronson Commercial	$729.56

PR GLOSSECTOMY HEMIGLOSSECTOMY

Professional

Both

$2,341.00

Service Code	HCPCS 41130
Min. Negotiated Rate	$761.81
Max. Negotiated Rate	$2,314.26
Rate for Payer: Aetna Commercial	$1,746.53
Rate for Payer: BCBS Complete	$876.93
Rate for Payer: BCBS Trust/PPO	$761.81
Rate for Payer: Cash Price	$1,872.80
Rate for Payer: Cash Price	$1,872.80
Rate for Payer: Meridian Medicaid	$876.93
Rate for Payer: Priority Health Choice Medicaid	$835.17
Rate for Payer: Priority Health Cigna Priority Health	$1,638.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,314.26
Rate for Payer: Priority Health Narrow Network	$2,314.26
Rate for Payer: Priority Health SBD	$2,314.26
Rate for Payer: UMR Bronson Commercial	$1,076.86

PR GLOSSECTOMY <ONE-HALF TONGUE

Professional

Both

$1,863.00

Service Code	HCPCS 41120
Min. Negotiated Rate	$640.83
Max. Negotiated Rate	$1,873.88
Rate for Payer: Aetna Commercial	$1,414.53
Rate for Payer: BCBS Complete	$708.97
Rate for Payer: BCBS Trust/PPO	$640.83
Rate for Payer: Cash Price	$1,490.40
Rate for Payer: Cash Price	$1,490.40
Rate for Payer: Meridian Medicaid	$708.97
Rate for Payer: Priority Health Choice Medicaid	$675.21
Rate for Payer: Priority Health Cigna Priority Health	$1,304.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,873.88
Rate for Payer: Priority Health Narrow Network	$1,873.88
Rate for Payer: Priority Health SBD	$1,873.88
Rate for Payer: UMR Bronson Commercial	$856.98

PR GLOSSECTOMY PRTL W/UNI RADICAL NECK DSJ

Professional

Both

$3,868.00

Service Code	HCPCS 41135
Min. Negotiated Rate	$438.49
Max. Negotiated Rate	$3,804.18
Rate for Payer: Aetna Commercial	$2,879.11
Rate for Payer: BCBS Complete	$1,445.23
Rate for Payer: BCBS Trust/PPO	$438.49
Rate for Payer: Cash Price	$3,094.40
Rate for Payer: Cash Price	$3,094.40
Rate for Payer: Meridian Medicaid	$1,445.23
Rate for Payer: Priority Health Choice Medicaid	$1,376.41
Rate for Payer: Priority Health Cigna Priority Health	$2,707.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$3,804.18
Rate for Payer: Priority Health Narrow Network	$3,804.18
Rate for Payer: Priority Health SBD	$3,804.18
Rate for Payer: UMR Bronson Commercial	$1,779.28

PR GLSSC COMPOSIT W/RESCJ FLOOR & MANDIBULAR RESCJ

Professional

Both

$4,018.00

Service Code	HCPCS 41150
Min. Negotiated Rate	$567.92
Max. Negotiated Rate	$3,862.39
Rate for Payer: Aetna Commercial	$2,915.24
Rate for Payer: BCBS Complete	$1,466.47
Rate for Payer: BCBS Trust/PPO	$567.92
Rate for Payer: Cash Price	$3,214.40
Rate for Payer: Cash Price	$3,214.40
Rate for Payer: Meridian Medicaid	$1,466.47
Rate for Payer: Priority Health Choice Medicaid	$1,396.64
Rate for Payer: Priority Health Cigna Priority Health	$2,812.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$3,862.39
Rate for Payer: Priority Health Narrow Network	$3,862.39
Rate for Payer: Priority Health SBD	$3,862.39
Rate for Payer: UMR Bronson Commercial	$1,848.28

PR GONIOSCOPY SEPARATE PROCEDURE

Professional

Both

$51.00

Service Code	HCPCS 92020
Min. Negotiated Rate	$12.78
Max. Negotiated Rate	$1,100.98
Rate for Payer: Aetna Commercial	$21.92
Rate for Payer: BCBS Complete	$13.42
Rate for Payer: BCBS Trust/PPO	$1,100.98
Rate for Payer: Cash Price	$40.80
Rate for Payer: Cash Price	$40.80
Rate for Payer: Meridian Medicaid	$13.42
Rate for Payer: Priority Health Choice Medicaid	$12.78
Rate for Payer: Priority Health Cigna Priority Health	$35.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$24.09
Rate for Payer: Priority Health Narrow Network	$24.09
Rate for Payer: Priority Health SBD	$24.09
Rate for Payer: UMR Bronson Commercial	$23.46

PR GRAFT COMPOSITE W/PRIMARY CLOSURE DONOR AREA

Professional

Both

$1,670.00

Service Code	HCPCS 15760
Min. Negotiated Rate	$446.66
Max. Negotiated Rate	$12,622.63
Rate for Payer: Aetna Commercial	$749.79
Rate for Payer: BCBS Complete	$468.99
Rate for Payer: BCBS Trust/PPO	$12,622.63
Rate for Payer: Cash Price	$1,336.00
Rate for Payer: Cash Price	$1,336.00
Rate for Payer: Meridian Medicaid	$468.99
Rate for Payer: Priority Health Choice Medicaid	$446.66
Rate for Payer: Priority Health Cigna Priority Health	$1,169.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$857.84
Rate for Payer: Priority Health Narrow Network	$857.84
Rate for Payer: Priority Health SBD	$857.84
Rate for Payer: UMR Bronson Commercial	$768.20

PR GRAFT DERMA-FAT-FASCIA

Professional

Both

$1,440.00

Service Code	HCPCS 15770
Min. Negotiated Rate	$432.60
Max. Negotiated Rate	$12,622.63
Rate for Payer: Aetna Commercial	$716.30
Rate for Payer: BCBS Complete	$454.23
Rate for Payer: BCBS Trust/PPO	$12,622.63
Rate for Payer: Cash Price	$1,152.00
Rate for Payer: Cash Price	$1,152.00
Rate for Payer: Meridian Medicaid	$454.23
Rate for Payer: Priority Health Choice Medicaid	$432.60
Rate for Payer: Priority Health Cigna Priority Health	$1,008.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$826.18
Rate for Payer: Priority Health Narrow Network	$826.18
Rate for Payer: Priority Health SBD	$826.18
Rate for Payer: UMR Bronson Commercial	$662.40

PR GRAFT EAR CRTLG AUTOGENOUS NOSE/EAR

Professional

Both

$1,201.00

Service Code	HCPCS 21235
Min. Negotiated Rate	$33.96
Max. Negotiated Rate	$871.18
Rate for Payer: Aetna Commercial	$741.79
Rate for Payer: BCBS Complete	$385.57
Rate for Payer: BCBS Trust/PPO	$33.96
Rate for Payer: Cash Price	$960.80
Rate for Payer: Cash Price	$960.80
Rate for Payer: Meridian Medicaid	$385.57
Rate for Payer: Priority Health Choice Medicaid	$367.21
Rate for Payer: Priority Health Cigna Priority Health	$840.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$871.18
Rate for Payer: Priority Health Narrow Network	$871.18
Rate for Payer: Priority Health SBD	$871.18
Rate for Payer: UMR Bronson Commercial	$552.46

PR GRAFTING OF AUTOLOGOUS FAT BY LIPO 25 CC OR LESS

Professional

Both

$1,145.00

Service Code	HCPCS 15773
Min. Negotiated Rate	$206.12
Max. Negotiated Rate	$801.50
Rate for Payer: Aetna Commercial	$519.36
Rate for Payer: BCBS Complete	$337.93
Rate for Payer: BCBS Trust/PPO	$206.12
Rate for Payer: Cash Price	$916.00
Rate for Payer: Cash Price	$916.00
Rate for Payer: Meridian Medicaid	$337.93
Rate for Payer: Priority Health Choice Medicaid	$321.84
Rate for Payer: Priority Health Cigna Priority Health	$801.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$615.74
Rate for Payer: Priority Health Narrow Network	$615.74
Rate for Payer: Priority Health SBD	$615.74
Rate for Payer: UMR Bronson Commercial	$526.70

PR GRAFTING OF AUTOLOGOUS FAT BY LIPO 50 CC OR LESS

Professional

Both

$1,134.00

Service Code	HCPCS 15771
Min. Negotiated Rate	$328.87
Max. Negotiated Rate	$793.80
Rate for Payer: Aetna Commercial	$514.12
Rate for Payer: BCBS Complete	$345.31
Rate for Payer: BCBS Trust/PPO	$529.69
Rate for Payer: Cash Price	$907.20
Rate for Payer: Cash Price	$907.20
Rate for Payer: Meridian Medicaid	$345.31
Rate for Payer: Priority Health Choice Medicaid	$328.87
Rate for Payer: Priority Health Cigna Priority Health	$793.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$624.78
Rate for Payer: Priority Health Narrow Network	$624.78
Rate for Payer: Priority Health SBD	$624.78
Rate for Payer: UMR Bronson Commercial	$521.64

PR GRAFTING OF AUTOLOGOUS FAT BY LIPO EA ADDL 25 CC

Professional

Both

$349.00

Service Code	HCPCS 15774
Min. Negotiated Rate	$90.74
Max. Negotiated Rate	$244.30
Rate for Payer: Aetna Commercial	$146.72
Rate for Payer: BCBS Complete	$95.28
Rate for Payer: BCBS Trust/PPO	$212.16
Rate for Payer: Cash Price	$279.20
Rate for Payer: Cash Price	$279.20
Rate for Payer: Meridian Medicaid	$95.28
Rate for Payer: Priority Health Choice Medicaid	$90.74
Rate for Payer: Priority Health Cigna Priority Health	$244.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$175.93
Rate for Payer: Priority Health Narrow Network	$175.93
Rate for Payer: Priority Health SBD	$175.93
Rate for Payer: UMR Bronson Commercial	$160.54

PR GRAFTING OF AUTOLOGOUS FAT BY LIPO EA ADDL 50 CC

Professional

Both

$360.00

Service Code	HCPCS 15772
Min. Negotiated Rate	$93.93
Max. Negotiated Rate	$6,614.63
Rate for Payer: Aetna Commercial	$152.33
Rate for Payer: BCBS Complete	$98.63
Rate for Payer: BCBS Trust/PPO	$6,614.63
Rate for Payer: Cash Price	$288.00
Rate for Payer: Cash Price	$288.00
Rate for Payer: Meridian Medicaid	$98.63
Rate for Payer: Priority Health Choice Medicaid	$93.93
Rate for Payer: Priority Health Cigna Priority Health	$252.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$180.85
Rate for Payer: Priority Health Narrow Network	$180.85
Rate for Payer: Priority Health SBD	$180.85
Rate for Payer: UMR Bronson Commercial	$165.60

PR GRAFTING OF AUTOLOGOUS SOFT TISS BY DIRECT EXC

Professional

Both

$956.00

Service Code	HCPCS 15769
Min. Negotiated Rate	$308.42
Max. Negotiated Rate	$669.20
Rate for Payer: Aetna Commercial	$517.80
Rate for Payer: BCBS Complete	$323.84
Rate for Payer: BCBS Trust/PPO	$543.75
Rate for Payer: Cash Price	$764.80
Rate for Payer: Cash Price	$764.80
Rate for Payer: Meridian Medicaid	$323.84
Rate for Payer: Priority Health Choice Medicaid	$308.42
Rate for Payer: Priority Health Cigna Priority Health	$669.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$591.49
Rate for Payer: Priority Health Narrow Network	$591.49
Rate for Payer: Priority Health SBD	$591.49
Rate for Payer: UMR Bronson Commercial	$439.76

PR GRAFT THIERSCH RCT INCONTINENCE &/PROLAPSE

Professional

Both

$1,176.00

Service Code	HCPCS 46753
Min. Negotiated Rate	$398.52
Max. Negotiated Rate	$1,095.99
Rate for Payer: Aetna Commercial	$835.54
Rate for Payer: BCBS Complete	$418.45
Rate for Payer: BCBS Trust/PPO	$586.41
Rate for Payer: Cash Price	$940.80
Rate for Payer: Cash Price	$940.80
Rate for Payer: Meridian Medicaid	$418.45
Rate for Payer: Priority Health Choice Medicaid	$398.52
Rate for Payer: Priority Health Cigna Priority Health	$823.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,095.99
Rate for Payer: Priority Health Narrow Network	$1,095.99
Rate for Payer: Priority Health SBD	$1,095.99
Rate for Payer: UMR Bronson Commercial	$540.96

PR GROUP BEHAVE COUNS 2-10

Professional

Both

$30.00

Service Code	HCPCS G0473
Min. Negotiated Rate	$10.97
Max. Negotiated Rate	$3,048.82
Rate for Payer: Aetna Commercial	$10.97
Rate for Payer: BCBS Complete	$12.00
Rate for Payer: BCBS Trust/PPO	$3,048.82
Rate for Payer: Cash Price	$24.00
Rate for Payer: Cash Price	$24.00
Rate for Payer: Priority Health Cigna Priority Health	$21.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$15.10
Rate for Payer: Priority Health Narrow Network	$15.10
Rate for Payer: Priority Health SBD	$15.10
Rate for Payer: UMR Bronson Commercial	$13.80

Know your out-of-pocket cost for care.

All Charges