Bronson Methodist Hospital

All Charges

Charge

Type

Setting

Price

PR LAIV4 VACCINE FOR INTRANASAL USE

Professional

Both

$31.00

Service Code	HCPCS 90672
Min. Negotiated Rate	$12.40
Max. Negotiated Rate	$27.79
Rate for Payer: Aetna Commercial	$27.79
Rate for Payer: BCBS Complete	$12.40
Rate for Payer: BCBS Trust/PPO	$27.54
Rate for Payer: Cash Price	$24.80
Rate for Payer: Cash Price	$24.80
Rate for Payer: Priority Health Cigna Priority Health	$21.70
Rate for Payer: UMR Bronson Commercial	$14.26

PR LAM BX/EXC ISPI NEO IDRL IMED CERVICAL

Professional

Both

$8,098.00

Service Code	HCPCS 63285
Min. Negotiated Rate	$381.43
Max. Negotiated Rate	$5,668.60
Rate for Payer: Aetna Commercial	$3,380.35
Rate for Payer: BCBS Complete	$1,778.24
Rate for Payer: BCBS Trust/PPO	$381.43
Rate for Payer: Cash Price	$6,478.40
Rate for Payer: Cash Price	$6,478.40
Rate for Payer: Meridian Medicaid	$1,778.24
Rate for Payer: Priority Health Choice Medicaid	$1,693.56
Rate for Payer: Priority Health Cigna Priority Health	$5,668.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$4,464.11
Rate for Payer: Priority Health Narrow Network	$4,464.11
Rate for Payer: Priority Health SBD	$4,464.11
Rate for Payer: UMR Bronson Commercial	$3,725.08

PR LAM BX/EXC ISPI NEO IDRL IMED THORACIC

Professional

Both

$8,116.00

Service Code	HCPCS 63286
Min. Negotiated Rate	$172.75
Max. Negotiated Rate	$5,681.20
Rate for Payer: Aetna Commercial	$3,337.98
Rate for Payer: BCBS Complete	$1,749.16
Rate for Payer: BCBS Trust/PPO	$172.75
Rate for Payer: Cash Price	$6,492.80
Rate for Payer: Cash Price	$6,492.80
Rate for Payer: Meridian Medicaid	$1,749.16
Rate for Payer: Priority Health Choice Medicaid	$1,665.87
Rate for Payer: Priority Health Cigna Priority Health	$5,681.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$4,419.93
Rate for Payer: Priority Health Narrow Network	$4,419.93
Rate for Payer: Priority Health SBD	$4,419.93
Rate for Payer: UMR Bronson Commercial	$3,733.36

PR LAM BX/EXC ISPI NEO IDRL IMED THORACOLMBR

Professional

Both

$8,577.00

Service Code	HCPCS 63287
Min. Negotiated Rate	$174.34
Max. Negotiated Rate	$6,003.90
Rate for Payer: Aetna Commercial	$3,546.68
Rate for Payer: BCBS Complete	$1,864.13
Rate for Payer: BCBS Trust/PPO	$174.34
Rate for Payer: Cash Price	$6,861.60
Rate for Payer: Cash Price	$6,861.60
Rate for Payer: Meridian Medicaid	$1,864.13
Rate for Payer: Priority Health Choice Medicaid	$1,775.36
Rate for Payer: Priority Health Cigna Priority Health	$6,003.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$4,680.96
Rate for Payer: Priority Health Narrow Network	$4,680.96
Rate for Payer: Priority Health SBD	$4,680.96
Rate for Payer: UMR Bronson Commercial	$3,945.42

PR LAM BX/EXC ISPI NEO IDRL SACRAL

Professional

Both

$6,162.00

Service Code	HCPCS 63283
Min. Negotiated Rate	$481.28
Max. Negotiated Rate	$4,313.40
Rate for Payer: Aetna Commercial	$2,457.79
Rate for Payer: BCBS Complete	$1,299.41
Rate for Payer: BCBS Trust/PPO	$481.28
Rate for Payer: Cash Price	$4,929.60
Rate for Payer: Cash Price	$4,929.60
Rate for Payer: Meridian Medicaid	$1,299.41
Rate for Payer: Priority Health Choice Medicaid	$1,237.53
Rate for Payer: Priority Health Cigna Priority Health	$4,313.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$3,259.19
Rate for Payer: Priority Health Narrow Network	$3,259.19
Rate for Payer: Priority Health SBD	$3,259.19
Rate for Payer: UMR Bronson Commercial	$2,834.52

PR LAM BX/EXC ISPI NEO IDRL XMED CERVICAL

Professional

Both

$7,440.00

Service Code	HCPCS 63280
Min. Negotiated Rate	$499.24
Max. Negotiated Rate	$5,208.00
Rate for Payer: Aetna Commercial	$2,742.34
Rate for Payer: BCBS Complete	$1,444.11
Rate for Payer: BCBS Trust/PPO	$499.24
Rate for Payer: Cash Price	$5,952.00
Rate for Payer: Cash Price	$5,952.00
Rate for Payer: Meridian Medicaid	$1,444.11
Rate for Payer: Priority Health Choice Medicaid	$1,375.34
Rate for Payer: Priority Health Cigna Priority Health	$5,208.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$3,622.69
Rate for Payer: Priority Health Narrow Network	$3,622.69
Rate for Payer: Priority Health SBD	$3,622.69
Rate for Payer: UMR Bronson Commercial	$3,422.40

PR LAM BX/EXC ISPI NEO IDRL XMED LUMBAR

Professional

Both

$7,844.00

Service Code	HCPCS 63282
Min. Negotiated Rate	$1,285.67
Max. Negotiated Rate	$5,490.80
Rate for Payer: Aetna Commercial	$2,559.02
Rate for Payer: BCBS Complete	$1,349.95
Rate for Payer: BCBS Trust/PPO	$1,388.14
Rate for Payer: Cash Price	$6,275.20
Rate for Payer: Cash Price	$6,275.20
Rate for Payer: Meridian Medicaid	$1,349.95
Rate for Payer: Priority Health Choice Medicaid	$1,285.67
Rate for Payer: Priority Health Cigna Priority Health	$5,490.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$3,388.85
Rate for Payer: Priority Health Narrow Network	$3,388.85
Rate for Payer: Priority Health SBD	$3,388.85
Rate for Payer: UMR Bronson Commercial	$3,608.24

PR LAM BX/EXC ISPI NEO IDRL XMED THORACIC

Professional

Both

$7,286.00

Service Code	HCPCS 63281
Min. Negotiated Rate	$1,364.05
Max. Negotiated Rate	$5,100.20
Rate for Payer: Aetna Commercial	$2,712.92
Rate for Payer: BCBS Complete	$1,432.25
Rate for Payer: BCBS Trust/PPO	$1,388.14
Rate for Payer: Cash Price	$5,828.80
Rate for Payer: Cash Price	$5,828.80
Rate for Payer: Meridian Medicaid	$1,432.25
Rate for Payer: Priority Health Choice Medicaid	$1,364.05
Rate for Payer: Priority Health Cigna Priority Health	$5,100.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$3,587.59
Rate for Payer: Priority Health Narrow Network	$3,587.59
Rate for Payer: Priority Health SBD	$3,587.59
Rate for Payer: UMR Bronson Commercial	$3,351.56

PR LAM BX/EXC ISPI NEO XDRL-IDRL LES ANY LVL

Professional

Both

$9,199.00

Service Code	HCPCS 63290
Min. Negotiated Rate	$213.43
Max. Negotiated Rate	$6,439.30
Rate for Payer: Aetna Commercial	$3,607.11
Rate for Payer: BCBS Complete	$1,895.44
Rate for Payer: BCBS Trust/PPO	$213.43
Rate for Payer: Cash Price	$7,359.20
Rate for Payer: Cash Price	$7,359.20
Rate for Payer: Meridian Medicaid	$1,895.44
Rate for Payer: Priority Health Choice Medicaid	$1,805.18
Rate for Payer: Priority Health Cigna Priority Health	$6,439.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$4,760.25
Rate for Payer: Priority Health Narrow Network	$4,760.25
Rate for Payer: Priority Health SBD	$4,760.25
Rate for Payer: UMR Bronson Commercial	$4,231.54

PR LAM EXC/EVAC ISPI LESION OTH/THN NEO XDRL LUMBAR

Professional

Both

$5,312.00

Service Code	HCPCS 63267
Min. Negotiated Rate	$244.07
Max. Negotiated Rate	$3,718.40
Rate for Payer: Aetna Commercial	$1,771.05
Rate for Payer: BCBS Complete	$933.51
Rate for Payer: BCBS Trust/PPO	$244.07
Rate for Payer: Cash Price	$4,249.60
Rate for Payer: Cash Price	$4,249.60
Rate for Payer: Meridian Medicaid	$933.51
Rate for Payer: Priority Health Choice Medicaid	$889.06
Rate for Payer: Priority Health Cigna Priority Health	$3,718.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,343.03
Rate for Payer: Priority Health Narrow Network	$2,343.03
Rate for Payer: Priority Health SBD	$2,343.03
Rate for Payer: UMR Bronson Commercial	$2,443.52

PR LAM EXC/EVAC ISPI LES OTH/THN NEO XDRL CERVICAL

Professional

Both

$5,705.00

Service Code	HCPCS 63265
Min. Negotiated Rate	$399.92
Max. Negotiated Rate	$3,993.50
Rate for Payer: Aetna Commercial	$2,154.82
Rate for Payer: BCBS Complete	$1,137.49
Rate for Payer: BCBS Trust/PPO	$399.92
Rate for Payer: Cash Price	$4,564.00
Rate for Payer: Cash Price	$4,564.00
Rate for Payer: Meridian Medicaid	$1,137.49
Rate for Payer: Priority Health Choice Medicaid	$1,083.32
Rate for Payer: Priority Health Cigna Priority Health	$3,993.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,854.33
Rate for Payer: Priority Health Narrow Network	$2,854.33
Rate for Payer: Priority Health SBD	$2,854.33
Rate for Payer: UMR Bronson Commercial	$2,624.30

PR LAM EXC/EVAC ISPI LES OTH/THN NEO XDRL SACRAL

Professional

Both

$4,507.00

Service Code	HCPCS 63268
Min. Negotiated Rate	$312.75
Max. Negotiated Rate	$3,154.90
Rate for Payer: Aetna Commercial	$1,833.95
Rate for Payer: BCBS Complete	$1,000.61
Rate for Payer: BCBS Trust/PPO	$312.75
Rate for Payer: Cash Price	$3,605.60
Rate for Payer: Cash Price	$3,605.60
Rate for Payer: Meridian Medicaid	$1,000.61
Rate for Payer: Priority Health Choice Medicaid	$952.96
Rate for Payer: Priority Health Cigna Priority Health	$3,154.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,391.17
Rate for Payer: Priority Health Narrow Network	$2,391.17
Rate for Payer: Priority Health SBD	$2,391.17
Rate for Payer: UMR Bronson Commercial	$2,073.22

PR LAM EXC/EVAC ISPI LES OTH/THN NEO XDRL THORACIC

Professional

Both

$5,800.00

Service Code	HCPCS 63266
Min. Negotiated Rate	$600.15
Max. Negotiated Rate	$4,060.00
Rate for Payer: Aetna Commercial	$2,225.81
Rate for Payer: BCBS Complete	$1,167.45
Rate for Payer: BCBS Trust/PPO	$600.15
Rate for Payer: Cash Price	$4,640.00
Rate for Payer: Cash Price	$4,640.00
Rate for Payer: Meridian Medicaid	$1,167.45
Rate for Payer: Priority Health Choice Medicaid	$1,111.86
Rate for Payer: Priority Health Cigna Priority Health	$4,060.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,934.73
Rate for Payer: Priority Health Narrow Network	$2,934.73
Rate for Payer: Priority Health SBD	$2,934.73
Rate for Payer: UMR Bronson Commercial	$2,668.00

PR LAM EXC ISPI LES OTH/THN NEO IDRL CERVICAL

Professional

Both

$6,089.00

Service Code	HCPCS 63270
Min. Negotiated Rate	$440.60
Max. Negotiated Rate	$4,262.30
Rate for Payer: Aetna Commercial	$2,685.45
Rate for Payer: BCBS Complete	$1,415.70
Rate for Payer: BCBS Trust/PPO	$440.60
Rate for Payer: Cash Price	$4,871.20
Rate for Payer: Cash Price	$4,871.20
Rate for Payer: Meridian Medicaid	$1,415.70
Rate for Payer: Priority Health Choice Medicaid	$1,348.29
Rate for Payer: Priority Health Cigna Priority Health	$4,262.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$3,554.19
Rate for Payer: Priority Health Narrow Network	$3,554.19
Rate for Payer: Priority Health SBD	$3,554.19
Rate for Payer: UMR Bronson Commercial	$2,800.94

PR LAM EXC ISPI LES OTH/THN NEO IDRL LUMBAR

Professional

Both

$6,418.00

Service Code	HCPCS 63272
Min. Negotiated Rate	$318.56
Max. Negotiated Rate	$4,492.60
Rate for Payer: Aetna Commercial	$2,414.96
Rate for Payer: BCBS Complete	$1,272.79
Rate for Payer: BCBS Trust/PPO	$318.56
Rate for Payer: Cash Price	$5,134.40
Rate for Payer: Cash Price	$5,134.40
Rate for Payer: Meridian Medicaid	$1,272.79
Rate for Payer: Priority Health Choice Medicaid	$1,212.18
Rate for Payer: Priority Health Cigna Priority Health	$4,492.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$3,186.70
Rate for Payer: Priority Health Narrow Network	$3,186.70
Rate for Payer: Priority Health SBD	$3,186.70
Rate for Payer: UMR Bronson Commercial	$2,952.28

PR LAM EXC ISPI LES OTH/THN NEO IDRL SACRAL

Professional

Both

$5,631.00

Service Code	HCPCS 63273
Min. Negotiated Rate	$580.07
Max. Negotiated Rate	$3,941.70
Rate for Payer: Aetna Commercial	$2,414.10
Rate for Payer: BCBS Complete	$1,274.80
Rate for Payer: BCBS Trust/PPO	$580.07
Rate for Payer: Cash Price	$4,504.80
Rate for Payer: Cash Price	$4,504.80
Rate for Payer: Meridian Medicaid	$1,274.80
Rate for Payer: Priority Health Choice Medicaid	$1,214.10
Rate for Payer: Priority Health Cigna Priority Health	$3,941.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$3,198.60
Rate for Payer: Priority Health Narrow Network	$3,198.60
Rate for Payer: Priority Health SBD	$3,198.60
Rate for Payer: UMR Bronson Commercial	$2,590.26

PR LAM EXC ISPI LES OTH/THN NEO IDRL THORACIC

Professional

Both

$5,990.00

Service Code	HCPCS 63271
Min. Negotiated Rate	$1,344.24
Max. Negotiated Rate	$4,193.00
Rate for Payer: Aetna Commercial	$2,678.93
Rate for Payer: BCBS Complete	$1,411.45
Rate for Payer: BCBS Trust/PPO	$1,388.14
Rate for Payer: Cash Price	$4,792.00
Rate for Payer: Cash Price	$4,792.00
Rate for Payer: Meridian Medicaid	$1,411.45
Rate for Payer: Priority Health Choice Medicaid	$1,344.24
Rate for Payer: Priority Health Cigna Priority Health	$4,193.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$3,551.36
Rate for Payer: Priority Health Narrow Network	$3,551.36
Rate for Payer: Priority Health SBD	$3,551.36
Rate for Payer: UMR Bronson Commercial	$2,755.40

PR LAM EXC/OCCLUSION AVM SPI CORD THORACOLUMBAR

Professional

Both

$6,341.00

Service Code	HCPCS 63252
Min. Negotiated Rate	$1,061.35
Max. Negotiated Rate	$5,167.36
Rate for Payer: Aetna Commercial	$3,918.18
Rate for Payer: BCBS Complete	$2,056.91
Rate for Payer: BCBS Trust/PPO	$1,061.35
Rate for Payer: Cash Price	$5,072.80
Rate for Payer: Cash Price	$5,072.80
Rate for Payer: Meridian Medicaid	$2,056.91
Rate for Payer: Priority Health Choice Medicaid	$1,958.96
Rate for Payer: Priority Health Cigna Priority Health	$4,438.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$5,167.36
Rate for Payer: Priority Health Narrow Network	$5,167.36
Rate for Payer: Priority Health SBD	$5,167.36
Rate for Payer: UMR Bronson Commercial	$2,916.86

PR LAM EXC/OCCLUSION AVM SPINAL CORD CERVICAL

Professional

Both

$4,781.00

Service Code	HCPCS 63250
Min. Negotiated Rate	$331.77
Max. Negotiated Rate	$5,055.24
Rate for Payer: Aetna Commercial	$3,834.83
Rate for Payer: BCBS Complete	$2,011.96
Rate for Payer: BCBS Trust/PPO	$331.77
Rate for Payer: Cash Price	$3,824.80
Rate for Payer: Cash Price	$3,824.80
Rate for Payer: Meridian Medicaid	$2,011.96
Rate for Payer: Priority Health Choice Medicaid	$1,916.15
Rate for Payer: Priority Health Cigna Priority Health	$3,346.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$5,055.24
Rate for Payer: Priority Health Narrow Network	$5,055.24
Rate for Payer: Priority Health SBD	$5,055.24
Rate for Payer: UMR Bronson Commercial	$2,199.26

PR LAM EXC/OCCLUSION AVM SPINAL CORD THORACIC

Professional

Both

$5,742.00

Service Code	HCPCS 63251
Min. Negotiated Rate	$725.36
Max. Negotiated Rate	$5,169.05
Rate for Payer: Aetna Commercial	$3,919.07
Rate for Payer: BCBS Complete	$2,057.13
Rate for Payer: BCBS Trust/PPO	$725.36
Rate for Payer: Cash Price	$4,593.60
Rate for Payer: Cash Price	$4,593.60
Rate for Payer: Meridian Medicaid	$2,057.13
Rate for Payer: Priority Health Choice Medicaid	$1,959.17
Rate for Payer: Priority Health Cigna Priority Health	$4,019.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$5,169.05
Rate for Payer: Priority Health Narrow Network	$5,169.05
Rate for Payer: Priority Health SBD	$5,169.05
Rate for Payer: UMR Bronson Commercial	$2,641.32

PR LAM FACETEC/FORAMOT DRG ARTHRD LMBR EA ADDL SGM

Professional

Both

$480.00

Service Code	HCPCS 63053
Min. Negotiated Rate	$146.12
Max. Negotiated Rate	$385.60
Rate for Payer: Aetna Commercial	$249.29
Rate for Payer: BCBS Complete	$153.43
Rate for Payer: BCBS Trust/PPO	$175.40
Rate for Payer: Cash Price	$384.00
Rate for Payer: Cash Price	$384.00
Rate for Payer: Meridian Medicaid	$153.43
Rate for Payer: Priority Health Choice Medicaid	$146.12
Rate for Payer: Priority Health Cigna Priority Health	$336.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$385.60
Rate for Payer: Priority Health Narrow Network	$385.60
Rate for Payer: Priority Health SBD	$385.60
Rate for Payer: UMR Bronson Commercial	$220.80

PR LAM FACETEC/FORAMOT DRG ARTHRD LUMBAR 1 VRT SGM

Professional

Both

$640.00

Service Code	HCPCS 63052
Min. Negotiated Rate	$164.44
Max. Negotiated Rate	$449.06
Rate for Payer: Aetna Commercial	$333.27
Rate for Payer: BCBS Complete	$172.66
Rate for Payer: BCBS Trust/PPO	$449.06
Rate for Payer: Cash Price	$512.00
Rate for Payer: Cash Price	$512.00
Rate for Payer: Meridian Medicaid	$172.66
Rate for Payer: Priority Health Choice Medicaid	$164.44
Rate for Payer: Priority Health Cigna Priority Health	$448.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$435.42
Rate for Payer: Priority Health Narrow Network	$435.42
Rate for Payer: Priority Health SBD	$435.42
Rate for Payer: UMR Bronson Commercial	$294.40

PR LAM FACETECTOMY&FORAMOT 1 VRT SGM EA ADDL SGM

Professional

Both

$2,263.00

Service Code	HCPCS 63048
Min. Negotiated Rate	$134.19
Max. Negotiated Rate	$1,584.10
Rate for Payer: Aetna Commercial	$273.78
Rate for Payer: BCBS Complete	$140.90
Rate for Payer: BCBS Trust/PPO	$347.09
Rate for Payer: Cash Price	$1,810.40
Rate for Payer: Cash Price	$1,810.40
Rate for Payer: Meridian Medicaid	$140.90
Rate for Payer: Priority Health Choice Medicaid	$134.19
Rate for Payer: Priority Health Cigna Priority Health	$1,584.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$354.45
Rate for Payer: Priority Health Narrow Network	$354.45
Rate for Payer: Priority Health SBD	$354.45
Rate for Payer: UMR Bronson Commercial	$1,040.98

PR LAM FACETECTOMY & FORAMOTOMY 1 VRT SGM CERVICAL

Professional

Both

$2,625.32

Service Code	HCPCS 63045
Min. Negotiated Rate	$166.94
Max. Negotiated Rate	$2,199.21
Rate for Payer: Aetna Commercial	$1,661.20
Rate for Payer: BCBS Complete	$876.71
Rate for Payer: BCBS Trust/PPO	$166.94
Rate for Payer: Cash Price	$2,100.26
Rate for Payer: Cash Price	$2,100.26
Rate for Payer: Meridian Medicaid	$876.71
Rate for Payer: Priority Health Choice Medicaid	$834.96
Rate for Payer: Priority Health Cigna Priority Health	$1,837.72
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,199.21
Rate for Payer: Priority Health Narrow Network	$2,199.21
Rate for Payer: Priority Health SBD	$2,199.21
Rate for Payer: UMR Bronson Commercial	$1,207.65

PR LAM FACETECTOMY & FORAMOTOMY 1 VRT SGM LUMBAR

Professional

Both

$2,240.74

Service Code	HCPCS 63047
Min. Negotiated Rate	$364.00
Max. Negotiated Rate	$1,886.65
Rate for Payer: Aetna Commercial	$1,424.42
Rate for Payer: BCBS Complete	$751.68
Rate for Payer: BCBS Trust/PPO	$364.00
Rate for Payer: Cash Price	$1,792.59
Rate for Payer: Cash Price	$1,792.59
Rate for Payer: Meridian Medicaid	$751.68
Rate for Payer: Priority Health Choice Medicaid	$715.89
Rate for Payer: Priority Health Cigna Priority Health	$1,568.52
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,886.65
Rate for Payer: Priority Health Narrow Network	$1,886.65
Rate for Payer: Priority Health SBD	$1,886.65
Rate for Payer: UMR Bronson Commercial	$1,030.74

Know your out-of-pocket cost for care.

All Charges