Bronson Methodist Hospital

All Charges

Charge

Type

Setting

Price

PR INSERT GASTROSTOMY TUBE PERCUTANEOUS

Professional

Both

$375.00

Service Code	HCPCS 49440
Min. Negotiated Rate	$126.31
Max. Negotiated Rate	$583.24
Rate for Payer: Aetna Commercial	$270.42
Rate for Payer: BCBS Complete	$132.63
Rate for Payer: BCBS Trust/PPO	$583.24
Rate for Payer: Cash Price	$300.00
Rate for Payer: Cash Price	$300.00
Rate for Payer: Meridian Medicaid	$132.63
Rate for Payer: Priority Health Choice Medicaid	$126.31
Rate for Payer: Priority Health Cigna Priority Health	$262.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$349.85
Rate for Payer: Priority Health Narrow Network	$349.85
Rate for Payer: Priority Health SBD	$349.85
Rate for Payer: UMR Bronson Commercial	$172.50

PR INSERTION BREAST IMPLANT SAME DAY OF MASTECTOMY

Professional

Both

$1,680.00

Service Code	HCPCS 19340
Min. Negotiated Rate	$487.13
Max. Negotiated Rate	$1,176.00
Rate for Payer: Aetna Commercial	$818.17
Rate for Payer: BCBS Complete	$511.49
Rate for Payer: BCBS Trust/PPO	$562.50
Rate for Payer: Cash Price	$1,344.00
Rate for Payer: Cash Price	$1,344.00
Rate for Payer: Meridian Medicaid	$511.49
Rate for Payer: Priority Health Choice Medicaid	$487.13
Rate for Payer: Priority Health Cigna Priority Health	$1,176.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$935.52
Rate for Payer: Priority Health Narrow Network	$935.52
Rate for Payer: Priority Health SBD	$935.52
Rate for Payer: UMR Bronson Commercial	$772.80

PR INSERTION CERVICAL DILATOR SEPARATE PROCEDURE

Professional

Both

$155.00

Service Code	HCPCS 59200
Min. Negotiated Rate	$49.05
Max. Negotiated Rate	$108.50
Rate for Payer: Aetna Commercial	$49.05
Rate for Payer: BCBS Complete	$62.00
Rate for Payer: BCBS Trust/PPO	$90.87
Rate for Payer: Cash Price	$124.00
Rate for Payer: Cash Price	$124.00
Rate for Payer: Priority Health Cigna Priority Health	$108.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$62.33
Rate for Payer: Priority Health Narrow Network	$62.33
Rate for Payer: Priority Health SBD	$62.33
Rate for Payer: UMR Bronson Commercial	$71.30

PR INSERTION DRUG DELIVERY IMPLANT

Professional

Both

$223.00

Service Code	HCPCS 11981
Min. Negotiated Rate	$39.83
Max. Negotiated Rate	$977.96
Rate for Payer: Aetna Commercial	$69.83
Rate for Payer: BCBS Complete	$41.82
Rate for Payer: BCBS Trust/PPO	$977.96
Rate for Payer: Cash Price	$178.40
Rate for Payer: Cash Price	$178.40
Rate for Payer: Meridian Medicaid	$41.82
Rate for Payer: Priority Health Choice Medicaid	$39.83
Rate for Payer: Priority Health Cigna Priority Health	$156.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$76.45
Rate for Payer: Priority Health Narrow Network	$76.45
Rate for Payer: Priority Health SBD	$76.45
Rate for Payer: UMR Bronson Commercial	$102.58

PR INSERTION EPICARDIAL ELECTRODE OPEN

Professional

Both

$2,325.00

Service Code	HCPCS 33202
Min. Negotiated Rate	$485.85
Max. Negotiated Rate	$1,627.50
Rate for Payer: Aetna Commercial	$1,033.14
Rate for Payer: BCBS Complete	$510.14
Rate for Payer: BCBS Trust/PPO	$1,263.69
Rate for Payer: Cash Price	$1,860.00
Rate for Payer: Cash Price	$1,860.00
Rate for Payer: Meridian Medicaid	$510.14
Rate for Payer: Priority Health Choice Medicaid	$485.85
Rate for Payer: Priority Health Cigna Priority Health	$1,627.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,208.61
Rate for Payer: Priority Health Narrow Network	$1,208.61
Rate for Payer: Priority Health SBD	$1,208.61
Rate for Payer: UMR Bronson Commercial	$1,069.50

PR INSERTION FLOW DIRECTED CATHETER FOR MONITORING

Professional

Both

$836.00

Service Code	HCPCS 93503
Min. Negotiated Rate	$54.74
Max. Negotiated Rate	$585.20
Rate for Payer: Aetna Commercial	$118.36
Rate for Payer: BCBS Complete	$57.48
Rate for Payer: BCBS Trust/PPO	$456.45
Rate for Payer: Cash Price	$668.80
Rate for Payer: Cash Price	$668.80
Rate for Payer: Meridian Medicaid	$57.48
Rate for Payer: Priority Health Choice Medicaid	$54.74
Rate for Payer: Priority Health Cigna Priority Health	$585.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$122.00
Rate for Payer: Priority Health Narrow Network	$122.00
Rate for Payer: Priority Health SBD	$122.00
Rate for Payer: UMR Bronson Commercial	$384.56

PR INSERTION INDWELLING TUNNELED PLEURAL CATHETER

Professional

Both

$1,912.00

Service Code	HCPCS 32550
Min. Negotiated Rate	$127.80
Max. Negotiated Rate	$1,338.40
Rate for Payer: Aetna Commercial	$264.99
Rate for Payer: BCBS Complete	$134.19
Rate for Payer: BCBS Trust/PPO	$421.58
Rate for Payer: Cash Price	$1,529.60
Rate for Payer: Cash Price	$1,529.60
Rate for Payer: Meridian Medicaid	$134.19
Rate for Payer: Priority Health Choice Medicaid	$127.80
Rate for Payer: Priority Health Cigna Priority Health	$1,338.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$277.82
Rate for Payer: Priority Health Narrow Network	$277.82
Rate for Payer: Priority Health SBD	$277.82
Rate for Payer: UMR Bronson Commercial	$879.52

PR INSERTION INTRA-AORTIC BALLOON ASSIST DEV PERQ

Professional

Both

$736.00

Service Code	HCPCS 33967
Min. Negotiated Rate	$161.24
Max. Negotiated Rate	$815.17
Rate for Payer: Aetna Commercial	$349.07
Rate for Payer: BCBS Complete	$169.30
Rate for Payer: BCBS Trust/PPO	$815.17
Rate for Payer: Cash Price	$588.80
Rate for Payer: Cash Price	$588.80
Rate for Payer: Meridian Medicaid	$169.30
Rate for Payer: Priority Health Choice Medicaid	$161.24
Rate for Payer: Priority Health Cigna Priority Health	$515.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$400.56
Rate for Payer: Priority Health Narrow Network	$400.56
Rate for Payer: Priority Health SBD	$400.56
Rate for Payer: UMR Bronson Commercial	$338.56

PR INSERTION INTRAUTERINE DEVICE IUD

Facility

$290.00

Service Code	CPT 58300
Hospital Charge Code	58300
Hospital Revenue Code	521
Min. Negotiated Rate	$127.60
Max. Negotiated Rate	$261.00
Rate for Payer: Aetna American Axle	$188.50
Rate for Payer: Aetna Commercial	$246.50
Rate for Payer: Aetna New Business (MI Preferred)	$188.50
Rate for Payer: Cash Price	$232.00
Rate for Payer: Cofinity Commercial	$249.40
Rate for Payer: Cofinity Commercial	$203.00
Rate for Payer: Encore Health Key Benefits Commercial	$232.00
Rate for Payer: Healthscope Commercial	$261.00
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial	$203.00
Rate for Payer: Lakeland Regional Health Systems Commercial	$217.50
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$246.50
Rate for Payer: PHP Commercial	$246.50
Rate for Payer: Priority Health Cigna Priority Health	$203.00
Rate for Payer: Priority Health SBD	$182.70
Rate for Payer: UMR Bronson Commercial	$127.60
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$217.50

PR INSERTION INTRAUTERINE DEVICE IUD

Professional

Both

$290.00

Service Code	HCPCS 58300
Min. Negotiated Rate	$31.95
Max. Negotiated Rate	$417.36
Rate for Payer: Aetna Commercial	$60.86
Rate for Payer: BCBS Complete	$33.55
Rate for Payer: BCBS Trust/PPO	$417.36
Rate for Payer: Cash Price	$232.00
Rate for Payer: Cash Price	$232.00
Rate for Payer: Meridian Medicaid	$33.55
Rate for Payer: Priority Health Choice Medicaid	$31.95
Rate for Payer: Priority Health Cigna Priority Health	$203.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$71.01
Rate for Payer: Priority Health Narrow Network	$71.01
Rate for Payer: Priority Health SBD	$71.01
Rate for Payer: UMR Bronson Commercial	$133.40

PR INSERTION INTRAUTERINE DEVICE IUD

Facility

$290.00

Service Code	CPT 58300
Hospital Charge Code	58300
Hospital Revenue Code	521
Min. Negotiated Rate	$49.12
Max. Negotiated Rate	$722.81
Rate for Payer: Aetna American Axle	$188.50
Rate for Payer: Aetna Commercial	$246.50
Rate for Payer: Aetna New Business (MI Preferred)	$188.50
Rate for Payer: BCBS Complete	$116.00
Rate for Payer: BCBS Trust/PPO	$722.81
Rate for Payer: Cash Price	$232.00
Rate for Payer: Cash Price	$232.00
Rate for Payer: Cofinity Commercial	$249.40
Rate for Payer: Cofinity Commercial	$203.00
Rate for Payer: Encore Health Key Benefits Commercial	$232.00
Rate for Payer: Healthscope Commercial	$261.00
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial	$203.00
Rate for Payer: Lakeland Regional Health Systems Commercial	$217.50
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$246.50
Rate for Payer: PHP Commercial	$246.50
Rate for Payer: Priority Health Cigna Priority Health	$203.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$146.35
Rate for Payer: Priority Health Narrow Network	$117.08
Rate for Payer: Priority Health SBD	$182.70
Rate for Payer: UHC All Payor (Choice/PPO)	$54.03
Rate for Payer: UHC Exchange	$49.12
Rate for Payer: UMR Bronson Commercial	$107.30
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$217.50

PR INSERTION INTRAUTERINE DEVICE IUD

Professional

Both

$290.00

Service Code	HCPCS 58300
Hospital Charge Code	58300
Min. Negotiated Rate	$31.95
Max. Negotiated Rate	$417.36
Rate for Payer: Aetna Commercial	$60.86
Rate for Payer: BCBS Complete	$33.55
Rate for Payer: BCBS Trust/PPO	$417.36
Rate for Payer: Cash Price	$232.00
Rate for Payer: Cash Price	$232.00
Rate for Payer: Meridian Medicaid	$33.55
Rate for Payer: Priority Health Choice Medicaid	$31.95
Rate for Payer: Priority Health Cigna Priority Health	$203.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$71.01
Rate for Payer: Priority Health Narrow Network	$71.01
Rate for Payer: Priority Health SBD	$71.01
Rate for Payer: UMR Bronson Commercial	$133.40

PR INSERTION PICC W/O IMG GDN < 5 YR

Professional

Both

$171.00

Service Code	HCPCS 36568
Min. Negotiated Rate	$57.51
Max. Negotiated Rate	$967.32
Rate for Payer: Aetna Commercial	$123.67
Rate for Payer: BCBS Complete	$60.39
Rate for Payer: BCBS Trust/PPO	$967.32
Rate for Payer: Cash Price	$136.80
Rate for Payer: Cash Price	$136.80
Rate for Payer: Meridian Medicaid	$60.39
Rate for Payer: Priority Health Choice Medicaid	$57.51
Rate for Payer: Priority Health Cigna Priority Health	$119.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$144.15
Rate for Payer: Priority Health Narrow Network	$144.15
Rate for Payer: Priority Health SBD	$144.15
Rate for Payer: UMR Bronson Commercial	$78.66

PR INSERTION PICC W/O IMG GDN 5 YR/>

Professional

Both

$480.00

Service Code	HCPCS 36569
Min. Negotiated Rate	$59.43
Max. Negotiated Rate	$563.70
Rate for Payer: Aetna Commercial	$125.36
Rate for Payer: BCBS Complete	$62.40
Rate for Payer: BCBS Trust/PPO	$563.70
Rate for Payer: Cash Price	$384.00
Rate for Payer: Cash Price	$384.00
Rate for Payer: Meridian Medicaid	$62.40
Rate for Payer: Priority Health Choice Medicaid	$59.43
Rate for Payer: Priority Health Cigna Priority Health	$336.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$146.29
Rate for Payer: Priority Health Narrow Network	$146.29
Rate for Payer: Priority Health SBD	$146.29
Rate for Payer: UMR Bronson Commercial	$220.80

PR INSERTION PICC W/RS&I < 5 YR

Professional

Both

$827.00

Service Code	HCPCS 36572
Min. Negotiated Rate	$50.69
Max. Negotiated Rate	$1,072.45
Rate for Payer: Aetna Commercial	$121.47
Rate for Payer: BCBS Complete	$53.22
Rate for Payer: BCBS Trust/PPO	$1,072.45
Rate for Payer: Cash Price	$661.60
Rate for Payer: Cash Price	$661.60
Rate for Payer: Meridian Medicaid	$53.22
Rate for Payer: Priority Health Choice Medicaid	$50.69
Rate for Payer: Priority Health Cigna Priority Health	$578.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$126.60
Rate for Payer: Priority Health Narrow Network	$126.60
Rate for Payer: Priority Health SBD	$126.60
Rate for Payer: UMR Bronson Commercial	$380.42

PR INSERTION PICC W/RS&I 5 YR/>

Professional

Both

$761.00

Service Code	HCPCS 36573
Min. Negotiated Rate	$51.97
Max. Negotiated Rate	$921.36
Rate for Payer: Aetna Commercial	$112.87
Rate for Payer: BCBS Complete	$54.57
Rate for Payer: BCBS Trust/PPO	$921.36
Rate for Payer: Cash Price	$608.80
Rate for Payer: Cash Price	$608.80
Rate for Payer: Meridian Medicaid	$54.57
Rate for Payer: Priority Health Choice Medicaid	$51.97
Rate for Payer: Priority Health Cigna Priority Health	$532.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$131.39
Rate for Payer: Priority Health Narrow Network	$131.39
Rate for Payer: Priority Health SBD	$131.39
Rate for Payer: UMR Bronson Commercial	$350.06

PR INSERTION/RPLCMT PERIPHERAL/GASTRIC NPGR

Professional

Both

$975.00

Service Code	HCPCS 64590
Min. Negotiated Rate	$188.08
Max. Negotiated Rate	$1,604.98
Rate for Payer: Aetna Commercial	$205.58
Rate for Payer: BCBS Complete	$197.48
Rate for Payer: BCBS Trust/PPO	$1,604.98
Rate for Payer: Cash Price	$780.00
Rate for Payer: Cash Price	$780.00
Rate for Payer: Meridian Medicaid	$197.48
Rate for Payer: Priority Health Choice Medicaid	$188.08
Rate for Payer: Priority Health Cigna Priority Health	$682.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$271.22
Rate for Payer: Priority Health Narrow Network	$271.22
Rate for Payer: Priority Health SBD	$271.22
Rate for Payer: UMR Bronson Commercial	$448.50

PR INSERTION SUBQ CARDIAC RHYTHM MONITOR W/PRGRMG

Professional

Both

$263.00

Service Code	HCPCS 33285
Min. Negotiated Rate	$54.74
Max. Negotiated Rate	$1,495.09
Rate for Payer: Aetna Commercial	$118.22
Rate for Payer: BCBS Complete	$57.48
Rate for Payer: BCBS Trust/PPO	$1,495.09
Rate for Payer: Cash Price	$210.40
Rate for Payer: Cash Price	$210.40
Rate for Payer: Meridian Medicaid	$57.48
Rate for Payer: Priority Health Choice Medicaid	$54.74
Rate for Payer: Priority Health Cigna Priority Health	$184.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$137.78
Rate for Payer: Priority Health Narrow Network	$137.78
Rate for Payer: Priority Health SBD	$137.78
Rate for Payer: UMR Bronson Commercial	$120.98

PR INSERTION TANDEM CUFF

Professional

Both

$1,487.00

Service Code	HCPCS 53444
Min. Negotiated Rate	$504.60
Max. Negotiated Rate	$2,999.16
Rate for Payer: Aetna Commercial	$1,018.14
Rate for Payer: BCBS Complete	$529.83
Rate for Payer: BCBS Trust/PPO	$2,999.16
Rate for Payer: Cash Price	$1,189.60
Rate for Payer: Cash Price	$1,189.60
Rate for Payer: Meridian Medicaid	$529.83
Rate for Payer: Priority Health Choice Medicaid	$504.60
Rate for Payer: Priority Health Cigna Priority Health	$1,040.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,263.89
Rate for Payer: Priority Health Narrow Network	$1,263.89
Rate for Payer: Priority Health SBD	$1,263.89
Rate for Payer: UMR Bronson Commercial	$684.02

PR INSERTION TUNNEL INTRAPERITONEAL CATH DIAL OPEN

Professional

Both

$1,282.00

Service Code	HCPCS 49421
Min. Negotiated Rate	$143.35
Max. Negotiated Rate	$2,980.67
Rate for Payer: Aetna Commercial	$308.24
Rate for Payer: BCBS Complete	$150.52
Rate for Payer: BCBS Trust/PPO	$2,980.67
Rate for Payer: Cash Price	$1,025.60
Rate for Payer: Cash Price	$1,025.60
Rate for Payer: Meridian Medicaid	$150.52
Rate for Payer: Priority Health Choice Medicaid	$143.35
Rate for Payer: Priority Health Cigna Priority Health	$897.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$393.93
Rate for Payer: Priority Health Narrow Network	$393.93
Rate for Payer: Priority Health SBD	$393.93
Rate for Payer: UMR Bronson Commercial	$589.72

PR INSERTION VAGINAL RADIATION DEVICE

Professional

Both

$383.00

Service Code	HCPCS 57156
Min. Negotiated Rate	$96.28
Max. Negotiated Rate	$2,560.67
Rate for Payer: Aetna Commercial	$176.91
Rate for Payer: BCBS Complete	$101.09
Rate for Payer: BCBS Trust/PPO	$2,560.67
Rate for Payer: Cash Price	$306.40
Rate for Payer: Cash Price	$306.40
Rate for Payer: Meridian Medicaid	$101.09
Rate for Payer: Priority Health Choice Medicaid	$96.28
Rate for Payer: Priority Health Cigna Priority Health	$268.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$213.51
Rate for Payer: Priority Health Narrow Network	$213.51
Rate for Payer: Priority Health SBD	$213.51
Rate for Payer: UMR Bronson Commercial	$176.18

PR INSERTION VASCULAR PEDICLE CARPAL BONE

Professional

Both

$1,211.00

Service Code	HCPCS 25430
Min. Negotiated Rate	$264.89
Max. Negotiated Rate	$1,128.54
Rate for Payer: Aetna Commercial	$974.68
Rate for Payer: BCBS Complete	$499.19
Rate for Payer: BCBS Trust/PPO	$264.89
Rate for Payer: Cash Price	$968.80
Rate for Payer: Cash Price	$968.80
Rate for Payer: Meridian Medicaid	$499.19
Rate for Payer: Priority Health Choice Medicaid	$475.42
Rate for Payer: Priority Health Cigna Priority Health	$847.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,128.54
Rate for Payer: Priority Health Narrow Network	$1,128.54
Rate for Payer: Priority Health SBD	$1,128.54
Rate for Payer: UMR Bronson Commercial	$557.06

PR INSERTION WIRE/PIN W/APPL SKELETAL TRACTION SPX

Professional

Both

$324.00

Service Code	HCPCS 20650
Min. Negotiated Rate	$63.44
Max. Negotiated Rate	$250.22
Rate for Payer: Aetna Commercial	$209.70
Rate for Payer: BCBS Complete	$113.17
Rate for Payer: BCBS Trust/PPO	$63.44
Rate for Payer: Cash Price	$259.20
Rate for Payer: Cash Price	$259.20
Rate for Payer: Meridian Medicaid	$113.17
Rate for Payer: Priority Health Choice Medicaid	$107.78
Rate for Payer: Priority Health Cigna Priority Health	$226.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$250.22
Rate for Payer: Priority Health Narrow Network	$250.22
Rate for Payer: Priority Health SBD	$250.22
Rate for Payer: UMR Bronson Commercial	$149.04

PR INSERT POST SPINOUS PROCESS DISTRACTION DEVICE, LUMBAR, EA ADD

Professional

Both

$519.00

Service Code	HCPCS 0172T
Min. Negotiated Rate	$207.60
Max. Negotiated Rate	$363.30
Rate for Payer: BCBS Complete	$207.60
Rate for Payer: Cash Price	$415.20
Rate for Payer: Priority Health Cigna Priority Health	$363.30
Rate for Payer: UMR Bronson Commercial	$238.74

PR INSERT POST SPINOUS PROCESS DISTRACTION DEVICE, LUMBAR, SINGLE

Professional

Both

$2,680.00

Service Code	HCPCS 0171T
Min. Negotiated Rate	$1,072.00
Max. Negotiated Rate	$1,876.00
Rate for Payer: BCBS Complete	$1,072.00
Rate for Payer: Cash Price	$2,144.00
Rate for Payer: Priority Health Cigna Priority Health	$1,876.00
Rate for Payer: UMR Bronson Commercial	$1,232.80

Know your out-of-pocket cost for care.

All Charges