Bronson Methodist Hospital

All Charges

Charge

Type

Setting

Price

PR INCISION & REMOVAL FOREIGN BODY SUBQ TISS SIMPLE

Professional

Both

$246.00

Service Code	HCPCS 10120
Hospital Charge Code	10120
Min. Negotiated Rate	$28.95
Max. Negotiated Rate	$172.20
Rate for Payer: Aetna Commercial	$110.83
Rate for Payer: BCBS Complete	$71.35
Rate for Payer: BCBS Trust/PPO	$28.95
Rate for Payer: Cash Price	$196.80
Rate for Payer: Cash Price	$196.80
Rate for Payer: Meridian Medicaid	$71.35
Rate for Payer: Priority Health Choice Medicaid	$67.95
Rate for Payer: Priority Health Cigna Priority Health	$172.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$129.07
Rate for Payer: Priority Health Narrow Network	$129.07
Rate for Payer: Priority Health SBD	$129.07
Rate for Payer: UMR Bronson Commercial	$113.16

PR INCISION & REMOVAL FOREIGN BODY SUBQ TISS SIMPLE

Facility

$246.00

Service Code	CPT 10120
Hospital Charge Code	10120
Hospital Revenue Code	521
Min. Negotiated Rate	$108.24
Max. Negotiated Rate	$221.40
Rate for Payer: Aetna American Axle	$159.90
Rate for Payer: Aetna Commercial	$209.10
Rate for Payer: Aetna New Business (MI Preferred)	$159.90
Rate for Payer: Cash Price	$196.80
Rate for Payer: Cofinity Commercial	$172.20
Rate for Payer: Cofinity Commercial	$211.56
Rate for Payer: Encore Health Key Benefits Commercial	$196.80
Rate for Payer: Healthscope Commercial	$221.40
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial	$172.20
Rate for Payer: Lakeland Regional Health Systems Commercial	$184.50
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$209.10
Rate for Payer: PHP Commercial	$209.10
Rate for Payer: Priority Health Cigna Priority Health	$172.20
Rate for Payer: Priority Health SBD	$154.98
Rate for Payer: UMR Bronson Commercial	$108.24
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$184.50

PR INCISION & SUBCUTANEOUS PLMT CRANIAL BONE GRAF

Professional

Both

$1,562.00

Service Code	HCPCS 61316
Min. Negotiated Rate	$56.02
Max. Negotiated Rate	$1,093.40
Rate for Payer: Aetna Commercial	$113.39
Rate for Payer: BCBS Complete	$58.82
Rate for Payer: BCBS Trust/PPO	$305.36
Rate for Payer: Cash Price	$1,249.60
Rate for Payer: Cash Price	$1,249.60
Rate for Payer: Meridian Medicaid	$58.82
Rate for Payer: Priority Health Choice Medicaid	$56.02
Rate for Payer: Priority Health Cigna Priority Health	$1,093.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$148.34
Rate for Payer: Priority Health Narrow Network	$148.34
Rate for Payer: Priority Health SBD	$148.34
Rate for Payer: UMR Bronson Commercial	$718.52

PR INCISION THROMBOSED HEMORRHOID EXTERNAL

Professional

Both

$352.00

Service Code	HCPCS 46083
Min. Negotiated Rate	$70.93
Max. Negotiated Rate	$2,366.78
Rate for Payer: Aetna Commercial	$145.09
Rate for Payer: BCBS Complete	$74.48
Rate for Payer: BCBS Trust/PPO	$2,366.78
Rate for Payer: Cash Price	$281.60
Rate for Payer: Cash Price	$281.60
Rate for Payer: Meridian Medicaid	$74.48
Rate for Payer: Priority Health Choice Medicaid	$70.93
Rate for Payer: Priority Health Cigna Priority Health	$246.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$193.45
Rate for Payer: Priority Health Narrow Network	$193.45
Rate for Payer: Priority Health SBD	$193.45
Rate for Payer: UMR Bronson Commercial	$161.92

PR INDIV PHYS SUPVJ HOME/DOM/R-HOME MO 30 MIN/>

Professional

Both

$214.00

Service Code	HCPCS 99340
Min. Negotiated Rate	$85.60
Max. Negotiated Rate	$149.80
Rate for Payer: BCBS Complete	$85.60
Rate for Payer: Cash Price	$171.20
Rate for Payer: Priority Health Cigna Priority Health	$149.80
Rate for Payer: UMR Bronson Commercial	$98.44

PR INDUCED ABORT 1/> VAG SUPP DLVR FETUS D&C &/EVAC

Professional

Both

$900.00

Service Code	HCPCS 59856
Min. Negotiated Rate	$321.63
Max. Negotiated Rate	$1,248.90
Rate for Payer: Aetna Commercial	$543.81
Rate for Payer: BCBS Complete	$337.71
Rate for Payer: BCBS Trust/PPO	$1,248.90
Rate for Payer: Cash Price	$720.00
Rate for Payer: Cash Price	$720.00
Rate for Payer: Meridian Medicaid	$337.71
Rate for Payer: Priority Health Choice Medicaid	$321.63
Rate for Payer: Priority Health Cigna Priority Health	$630.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$708.74
Rate for Payer: Priority Health Narrow Network	$708.74
Rate for Payer: Priority Health SBD	$708.74
Rate for Payer: UMR Bronson Commercial	$414.00

PR INDUCED ABORT 1/> VAG SUPPOS DLVR FETUS HYSTOT

Professional

Both

$1,793.00

Service Code	HCPCS 59857
Min. Negotiated Rate	$374.24
Max. Negotiated Rate	$1,255.10
Rate for Payer: Aetna Commercial	$636.21
Rate for Payer: BCBS Complete	$392.95
Rate for Payer: BCBS Trust/PPO	$756.53
Rate for Payer: Cash Price	$1,434.40
Rate for Payer: Cash Price	$1,434.40
Rate for Payer: Meridian Medicaid	$392.95
Rate for Payer: Priority Health Choice Medicaid	$374.24
Rate for Payer: Priority Health Cigna Priority Health	$1,255.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$825.84
Rate for Payer: Priority Health Narrow Network	$825.84
Rate for Payer: Priority Health SBD	$825.84
Rate for Payer: UMR Bronson Commercial	$824.78

PR INDUCED ABORT 1/> VAG SUPPOSITORIES DLVR FETUS

Professional

Both

$906.00

Service Code	HCPCS 59855
Min. Negotiated Rate	$275.20
Max. Negotiated Rate	$1,169.13
Rate for Payer: Aetna Commercial	$464.07
Rate for Payer: BCBS Complete	$288.96
Rate for Payer: BCBS Trust/PPO	$1,169.13
Rate for Payer: Cash Price	$724.80
Rate for Payer: Cash Price	$724.80
Rate for Payer: Meridian Medicaid	$288.96
Rate for Payer: Priority Health Choice Medicaid	$275.20
Rate for Payer: Priority Health Cigna Priority Health	$634.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$606.27
Rate for Payer: Priority Health Narrow Network	$606.27
Rate for Payer: Priority Health SBD	$606.27
Rate for Payer: UMR Bronson Commercial	$416.76

PR INDUCED ABORTION DILATION AND CURETTAGE

Professional

Both

$790.00

Service Code	HCPCS 59840
Min. Negotiated Rate	$143.99
Max. Negotiated Rate	$1,030.71
Rate for Payer: Aetna Commercial	$239.76
Rate for Payer: BCBS Complete	$151.19
Rate for Payer: BCBS Trust/PPO	$1,030.71
Rate for Payer: Cash Price	$632.00
Rate for Payer: Cash Price	$632.00
Rate for Payer: Meridian Medicaid	$151.19
Rate for Payer: Priority Health Choice Medicaid	$143.99
Rate for Payer: Priority Health Cigna Priority Health	$553.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$316.82
Rate for Payer: Priority Health Narrow Network	$316.82
Rate for Payer: Priority Health SBD	$316.82
Rate for Payer: UMR Bronson Commercial	$363.40

PR INDUCED ABORTION DILATION & EVACUATION

Professional

Both

$830.00

Service Code	HCPCS 59841
Min. Negotiated Rate	$240.90
Max. Negotiated Rate	$953.58
Rate for Payer: Aetna Commercial	$405.93
Rate for Payer: BCBS Complete	$252.94
Rate for Payer: BCBS Trust/PPO	$953.58
Rate for Payer: Cash Price	$664.00
Rate for Payer: Cash Price	$664.00
Rate for Payer: Meridian Medicaid	$252.94
Rate for Payer: Priority Health Choice Medicaid	$240.90
Rate for Payer: Priority Health Cigna Priority Health	$581.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$530.25
Rate for Payer: Priority Health Narrow Network	$530.25
Rate for Payer: Priority Health SBD	$530.25
Rate for Payer: UMR Bronson Commercial	$381.80

PR INDWELLING CATHETER SPECIAL

Professional

Both

$46.00

Service Code	HCPCS A4340
Min. Negotiated Rate	$18.40
Max. Negotiated Rate	$32.20
Rate for Payer: Aetna Commercial	$25.14
Rate for Payer: BCBS Complete	$18.40
Rate for Payer: Cash Price	$36.80
Rate for Payer: Cash Price	$36.80
Rate for Payer: Priority Health Cigna Priority Health	$32.20
Rate for Payer: UMR Bronson Commercial	$21.16

PR INFRATEMPO MID CRANIAL FOSSA W/WO DCOMPR&/MOBI

Professional

Both

$10,750.00

Service Code	HCPCS 61591
Min. Negotiated Rate	$366.64
Max. Negotiated Rate	$7,525.00
Rate for Payer: Aetna Commercial	$3,957.60
Rate for Payer: BCBS Complete	$2,065.85
Rate for Payer: BCBS Trust/PPO	$366.64
Rate for Payer: Cash Price	$8,600.00
Rate for Payer: Cash Price	$8,600.00
Rate for Payer: Meridian Medicaid	$2,065.85
Rate for Payer: Priority Health Choice Medicaid	$1,967.48
Rate for Payer: Priority Health Cigna Priority Health	$7,525.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$5,226.25
Rate for Payer: Priority Health Narrow Network	$5,226.25
Rate for Payer: Priority Health SBD	$5,226.25
Rate for Payer: UMR Bronson Commercial	$4,945.00

PR INFRATEMPORAL MID CRANIAL FOSSA W/WO DISARTICLTN

Professional

Both

$6,443.00

Service Code	HCPCS 61590
Min. Negotiated Rate	$514.56
Max. Negotiated Rate	$5,139.04
Rate for Payer: Aetna Commercial	$3,915.31
Rate for Payer: BCBS Complete	$2,029.18
Rate for Payer: BCBS Trust/PPO	$514.56
Rate for Payer: Cash Price	$5,154.40
Rate for Payer: Cash Price	$5,154.40
Rate for Payer: Meridian Medicaid	$2,029.18
Rate for Payer: Priority Health Choice Medicaid	$1,932.55
Rate for Payer: Priority Health Cigna Priority Health	$4,510.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$5,139.04
Rate for Payer: Priority Health Narrow Network	$5,139.04
Rate for Payer: Priority Health SBD	$5,139.04
Rate for Payer: UMR Bronson Commercial	$2,963.78

PR INGESTION CHALLENGE TEST EACH ADDL 60 MINUTES

Professional

Both

$167.00

Service Code	HCPCS 95079
Min. Negotiated Rate	$42.81
Max. Negotiated Rate	$376.15
Rate for Payer: Aetna Commercial	$70.38
Rate for Payer: BCBS Complete	$44.95
Rate for Payer: BCBS Trust/PPO	$376.15
Rate for Payer: Cash Price	$133.60
Rate for Payer: Cash Price	$133.60
Rate for Payer: Meridian Medicaid	$44.95
Rate for Payer: Priority Health Choice Medicaid	$42.81
Rate for Payer: Priority Health Cigna Priority Health	$116.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$83.60
Rate for Payer: Priority Health Narrow Network	$83.60
Rate for Payer: Priority Health SBD	$83.60
Rate for Payer: UMR Bronson Commercial	$76.82

PR INGESTION CHALLENGE TEST INITIAL 120 MINUTES

Professional

Both

$238.00

Service Code	HCPCS 95076
Min. Negotiated Rate	$46.43
Max. Negotiated Rate	$262.04
Rate for Payer: Aetna Commercial	$76.44
Rate for Payer: BCBS Complete	$48.75
Rate for Payer: BCBS Trust/PPO	$262.04
Rate for Payer: Cash Price	$190.40
Rate for Payer: Cash Price	$190.40
Rate for Payer: Meridian Medicaid	$48.75
Rate for Payer: Priority Health Choice Medicaid	$46.43
Rate for Payer: Priority Health Cigna Priority Health	$166.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$90.72
Rate for Payer: Priority Health Narrow Network	$90.72
Rate for Payer: Priority Health SBD	$90.72
Rate for Payer: UMR Bronson Commercial	$109.48

PR INGUINOFEM LMPHADEC SUPFC W/CLOQUETS NODE SPX

Professional

Both

$2,577.00

Service Code	HCPCS 38760
Min. Negotiated Rate	$536.12
Max. Negotiated Rate	$1,810.85
Rate for Payer: Aetna Commercial	$1,041.85
Rate for Payer: BCBS Complete	$562.93
Rate for Payer: BCBS Trust/PPO	$689.96
Rate for Payer: Cash Price	$2,061.60
Rate for Payer: Cash Price	$2,061.60
Rate for Payer: Meridian Medicaid	$562.93
Rate for Payer: Priority Health Choice Medicaid	$536.12
Rate for Payer: Priority Health Cigna Priority Health	$1,803.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,810.85
Rate for Payer: Priority Health Narrow Network	$1,810.85
Rate for Payer: Priority Health SBD	$1,810.85
Rate for Payer: UMR Bronson Commercial	$1,185.42

PR INGUINOFEM LMPHADEC SUPFC W/PEL LMPHADEC

Professional

Both

$2,653.64

Service Code	HCPCS 38765
Min. Negotiated Rate	$524.60
Max. Negotiated Rate	$2,830.72
Rate for Payer: Aetna Commercial	$1,622.20
Rate for Payer: BCBS Complete	$877.83
Rate for Payer: BCBS Trust/PPO	$524.60
Rate for Payer: Cash Price	$2,122.91
Rate for Payer: Cash Price	$2,122.91
Rate for Payer: Meridian Medicaid	$877.83
Rate for Payer: Priority Health Choice Medicaid	$836.03
Rate for Payer: Priority Health Cigna Priority Health	$1,857.55
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,830.72
Rate for Payer: Priority Health Narrow Network	$2,830.72
Rate for Payer: Priority Health SBD	$2,830.72
Rate for Payer: UMR Bronson Commercial	$1,220.67

PR INHLJ BRNCL CHALLENGE TSTG W/HISTAM/METHACHOL

Professional

Both

$244.00

Service Code	HCPCS 95070
Min. Negotiated Rate	$34.09
Max. Negotiated Rate	$302.19
Rate for Payer: Aetna Commercial	$34.09
Rate for Payer: BCBS Complete	$97.60
Rate for Payer: BCBS Trust/PPO	$302.19
Rate for Payer: Cash Price	$195.20
Rate for Payer: Cash Price	$195.20
Rate for Payer: Priority Health Cigna Priority Health	$170.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$43.05
Rate for Payer: Priority Health Narrow Network	$43.05
Rate for Payer: Priority Health SBD	$43.05
Rate for Payer: UMR Bronson Commercial	$112.24

PR INITIAL FOOT EXAM PT LOPS

Professional

Both

$96.00

Service Code	HCPCS G0245
Min. Negotiated Rate	$38.40
Max. Negotiated Rate	$90.34
Rate for Payer: Aetna Commercial	$41.41
Rate for Payer: BCBS Complete	$38.40
Rate for Payer: BCBS Trust/PPO	$90.34
Rate for Payer: Cash Price	$76.80
Rate for Payer: Cash Price	$76.80
Rate for Payer: Priority Health Cigna Priority Health	$67.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$40.72
Rate for Payer: Priority Health Narrow Network	$40.72
Rate for Payer: Priority Health SBD	$40.72
Rate for Payer: UMR Bronson Commercial	$44.16

PR INITIAL HOSP NEONATE 28 D/< NOT CRITICALLY ILL

Professional

Both

$1,044.00

Service Code	HCPCS 99477
Min. Negotiated Rate	$177.51
Max. Negotiated Rate	$730.80
Rate for Payer: Aetna Commercial	$342.16
Rate for Payer: BCBS Complete	$333.80
Rate for Payer: BCBS Trust/PPO	$177.51
Rate for Payer: Cash Price	$835.20
Rate for Payer: Cash Price	$835.20
Rate for Payer: Meridian Medicaid	$333.80
Rate for Payer: Priority Health Choice Medicaid	$317.90
Rate for Payer: Priority Health Cigna Priority Health	$730.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$428.75
Rate for Payer: Priority Health Narrow Network	$428.75
Rate for Payer: Priority Health SBD	$428.75
Rate for Payer: UMR Bronson Commercial	$480.24

PR INITIAL INPATIENT CONSULT NEW/ESTAB PT 20 MIN

Professional

Both

$131.00

Service Code	HCPCS 99251
Min. Negotiated Rate	$52.40
Max. Negotiated Rate	$91.70
Rate for Payer: BCBS Complete	$52.40
Rate for Payer: Cash Price	$104.80
Rate for Payer: Priority Health Cigna Priority Health	$91.70
Rate for Payer: UMR Bronson Commercial	$60.26

PR INITIAL NURSING FACILITY CARE HI MDM 45 MINUTES

Professional

Both

$246.00

Service Code	HCPCS 99306
Min. Negotiated Rate	$113.16
Max. Negotiated Rate	$2,045.58
Rate for Payer: Aetna Commercial	$163.22
Rate for Payer: BCBS Complete	$163.99
Rate for Payer: BCBS Trust/PPO	$2,045.58
Rate for Payer: Cash Price	$196.80
Rate for Payer: Cash Price	$196.80
Rate for Payer: Meridian Medicaid	$163.99
Rate for Payer: Priority Health Choice Medicaid	$156.18
Rate for Payer: Priority Health Cigna Priority Health	$172.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$230.43
Rate for Payer: Priority Health Narrow Network	$230.43
Rate for Payer: Priority Health SBD	$230.43
Rate for Payer: UMR Bronson Commercial	$113.16

PR INITIAL NURSING FACILITY CARE MOD MDM 35 MINUTES

Professional

Both

$193.00

Service Code	HCPCS 99305
Min. Negotiated Rate	$88.78
Max. Negotiated Rate	$1,949.96
Rate for Payer: Aetna Commercial	$126.84
Rate for Payer: BCBS Complete	$120.12
Rate for Payer: BCBS Trust/PPO	$1,949.96
Rate for Payer: Cash Price	$154.40
Rate for Payer: Cash Price	$154.40
Rate for Payer: Meridian Medicaid	$120.12
Rate for Payer: Priority Health Choice Medicaid	$114.40
Rate for Payer: Priority Health Cigna Priority Health	$135.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$168.76
Rate for Payer: Priority Health Narrow Network	$168.76
Rate for Payer: Priority Health SBD	$168.76
Rate for Payer: UMR Bronson Commercial	$88.78

PR INITIAL NURSING FACILITY CARE SF/LOW MDM 25 MIN

Professional

Both

$135.00

Service Code	HCPCS 99304
Min. Negotiated Rate	$62.10
Max. Negotiated Rate	$2,272.22
Rate for Payer: Aetna Commercial	$87.92
Rate for Payer: BCBS Complete	$72.31
Rate for Payer: BCBS Trust/PPO	$2,272.22
Rate for Payer: Cash Price	$108.00
Rate for Payer: Cash Price	$108.00
Rate for Payer: Meridian Medicaid	$72.31
Rate for Payer: Priority Health Choice Medicaid	$68.87
Rate for Payer: Priority Health Cigna Priority Health	$94.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$101.94
Rate for Payer: Priority Health Narrow Network	$101.94
Rate for Payer: Priority Health SBD	$101.94
Rate for Payer: UMR Bronson Commercial	$62.10

PR INITIAL OBSERVATION CARE/DAY 30 MINUTES

Professional

Both

$148.00

Service Code	HCPCS 99218
Min. Negotiated Rate	$59.20
Max. Negotiated Rate	$103.60
Rate for Payer: BCBS Complete	$59.20
Rate for Payer: Cash Price	$118.40
Rate for Payer: Priority Health Cigna Priority Health	$103.60
Rate for Payer: UMR Bronson Commercial	$68.08

Know your out-of-pocket cost for care.

All Charges