Bronson Methodist Hospital

All Charges

Charge

Type

Setting

Price

PR MAXILLECTOMY W/O ORBITAL EXENTERATION

Professional

Both

$3,239.00

Service Code	HCPCS 31225
Min. Negotiated Rate	$904.98
Max. Negotiated Rate	$2,505.08
Rate for Payer: Aetna Commercial	$2,328.96
Rate for Payer: BCBS Complete	$1,209.27
Rate for Payer: BCBS Trust/PPO	$904.98
Rate for Payer: Cash Price	$2,591.20
Rate for Payer: Cash Price	$2,591.20
Rate for Payer: Meridian Medicaid	$1,209.27
Rate for Payer: Priority Health Choice Medicaid	$1,151.69
Rate for Payer: Priority Health Cigna Priority Health	$2,267.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,505.08
Rate for Payer: Priority Health Narrow Network	$2,505.08
Rate for Payer: Priority Health SBD	$2,505.08
Rate for Payer: UMR Bronson Commercial	$1,489.94

PR MCCD, INITIAL RATE

Professional

Both

$160.00

Service Code	HCPCS G9001
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$1,218.26
Rate for Payer: Aetna Commercial	$0.01
Rate for Payer: BCBS Complete	$64.00
Rate for Payer: BCBS Trust/PPO	$1,218.26
Rate for Payer: Cash Price	$128.00
Rate for Payer: Cash Price	$128.00
Rate for Payer: Priority Health Cigna Priority Health	$112.00
Rate for Payer: UMR Bronson Commercial	$73.60

PR MCCD,MAINTENANCE RATE

Professional

Both

$80.00

Service Code	HCPCS G9002
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$884.37
Rate for Payer: Aetna Commercial	$0.01
Rate for Payer: BCBS Complete	$32.00
Rate for Payer: BCBS Trust/PPO	$884.37
Rate for Payer: Cash Price	$64.00
Rate for Payer: Cash Price	$64.00
Rate for Payer: Priority Health Cigna Priority Health	$56.00
Rate for Payer: UMR Bronson Commercial	$36.80

PR MCCD,PHYS COOR-CARE OVRSGHT

Professional

Both

$85.00

Service Code	HCPCS G9008
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$1,823.69
Rate for Payer: Aetna Commercial	$0.01
Rate for Payer: BCBS Complete	$34.00
Rate for Payer: BCBS Trust/PPO	$1,823.69
Rate for Payer: Cash Price	$68.00
Rate for Payer: Cash Price	$68.00
Rate for Payer: Priority Health Cigna Priority Health	$59.50
Rate for Payer: UMR Bronson Commercial	$39.10

PR MCCD, SCH TEAM CONF

Professional

Both

$40.00

Service Code	HCPCS G9007
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$1,852.75
Rate for Payer: Aetna Commercial	$0.01
Rate for Payer: BCBS Complete	$16.00
Rate for Payer: BCBS Trust/PPO	$1,852.75
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 MCHNL RMVL INTRAL OBSTR CV DEV THRU DEV LUMEN

Professional

Both

$231.00

Service Code	HCPCS 36596
Min. Negotiated Rate	$28.33
Max. Negotiated Rate	$745.43
Rate for Payer: Aetna Commercial	$57.96
Rate for Payer: BCBS Complete	$29.75
Rate for Payer: BCBS Trust/PPO	$745.43
Rate for Payer: Cash Price	$184.80
Rate for Payer: Cash Price	$184.80
Rate for Payer: Meridian Medicaid	$29.75
Rate for Payer: Priority Health Choice Medicaid	$28.33
Rate for Payer: Priority Health Cigna Priority Health	$161.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$69.15
Rate for Payer: Priority Health Narrow Network	$69.15
Rate for Payer: Priority Health SBD	$69.15
Rate for Payer: UMR Bronson Commercial	$106.26

PR MCHNL RMVL PRICATH OBSTR CV DEV VIA VEN ACCESS

Professional

Both

$1,120.00

Service Code	HCPCS 36595
Min. Negotiated Rate	$112.68
Max. Negotiated Rate	$784.00
Rate for Payer: Aetna Commercial	$243.74
Rate for Payer: BCBS Complete	$118.31
Rate for Payer: BCBS Trust/PPO	$586.94
Rate for Payer: Cash Price	$896.00
Rate for Payer: Cash Price	$896.00
Rate for Payer: Meridian Medicaid	$118.31
Rate for Payer: Priority Health Choice Medicaid	$112.68
Rate for Payer: Priority Health Cigna Priority Health	$784.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$281.40
Rate for Payer: Priority Health Narrow Network	$281.40
Rate for Payer: Priority Health SBD	$281.40
Rate for Payer: UMR Bronson Commercial	$515.20

PR MD CERTIFICATION HHA PATIENT

Professional

Both

$102.00

Service Code	HCPCS G0180
Min. Negotiated Rate	$40.80
Max. Negotiated Rate	$76.60
Rate for Payer: Aetna Commercial	$51.34
Rate for Payer: BCBS Complete	$40.80
Rate for Payer: BCBS Trust/PPO	$76.60
Rate for Payer: Cash Price	$81.60
Rate for Payer: Cash Price	$81.60
Rate for Payer: Priority Health Cigna Priority Health	$71.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$69.62
Rate for Payer: Priority Health Narrow Network	$69.62
Rate for Payer: Priority Health SBD	$69.62
Rate for Payer: UMR Bronson Commercial	$46.92

PR MD RECERTIFICATION HHA PT

Professional

Both

$77.00

Service Code	HCPCS G0179
Min. Negotiated Rate	$30.80
Max. Negotiated Rate	$83.63
Rate for Payer: Aetna Commercial	$39.71
Rate for Payer: BCBS Complete	$30.80
Rate for Payer: BCBS Trust/PPO	$83.63
Rate for Payer: Cash Price	$61.60
Rate for Payer: Cash Price	$61.60
Rate for Payer: Priority Health Cigna Priority Health	$53.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$55.24
Rate for Payer: Priority Health Narrow Network	$55.24
Rate for Payer: Priority Health SBD	$55.24
Rate for Payer: UMR Bronson Commercial	$35.42

PR MD REVIEW INTERPRET OF TEST

Professional

Both

$30.00

Service Code	HCPCS G0250
Min. Negotiated Rate	$7.97
Max. Negotiated Rate	$459.09
Rate for Payer: Aetna Commercial	$7.97
Rate for Payer: BCBS Complete	$12.00
Rate for Payer: BCBS Trust/PPO	$459.09
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	$11.14
Rate for Payer: Priority Health Narrow Network	$11.14
Rate for Payer: Priority Health SBD	$11.14
Rate for Payer: UMR Bronson Commercial	$13.80

PR MD SERVICE REQUIRED FOR PMD

Professional

Both

$28.00

Service Code	HCPCS G0372
Min. Negotiated Rate	$8.90
Max. Negotiated Rate	$1,453.88
Rate for Payer: Aetna Commercial	$8.90
Rate for Payer: BCBS Complete	$11.20
Rate for Payer: BCBS Trust/PPO	$1,453.88
Rate for Payer: Cash Price	$22.40
Rate for Payer: Cash Price	$22.40
Rate for Payer: Priority Health Cigna Priority Health	$19.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$11.68
Rate for Payer: Priority Health Narrow Network	$11.68
Rate for Payer: Priority Health SBD	$11.68
Rate for Payer: UMR Bronson Commercial	$12.88

PR MEASLES MUMPS RUBELLA VARICELLA VACC LIVE SUBQ

Professional

Both

$300.00

Service Code	HCPCS 90710
Min. Negotiated Rate	$120.00
Max. Negotiated Rate	$275.04
Rate for Payer: Aetna Commercial	$275.04
Rate for Payer: BCBS Complete	$120.00
Rate for Payer: BCBS Trust/PPO	$260.00
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 MEASLES MUMPS RUBELLA VIRUS VACCINE LIVE SUBQ

Professional

Both

$105.00

Service Code	HCPCS 90707
Min. Negotiated Rate	$42.00
Max. Negotiated Rate	$94.50
Rate for Payer: Aetna Commercial	$94.50
Rate for Payer: BCBS Complete	$42.00
Rate for Payer: BCBS Trust/PPO	$88.32
Rate for Payer: Cash Price	$84.00
Rate for Payer: Cash Price	$84.00
Rate for Payer: Priority Health Cigna Priority Health	$73.50
Rate for Payer: UMR Bronson Commercial	$48.30

PR MEAS POST-VOIDING RESIDUAL URINE&/BLADDER CAP

Professional

Both

$33.00

Service Code	HCPCS 51798
Min. Negotiated Rate	$12.43
Max. Negotiated Rate	$3,662.70
Rate for Payer: Aetna Commercial	$12.43
Rate for Payer: BCBS Complete	$13.20
Rate for Payer: BCBS Trust/PPO	$3,662.70
Rate for Payer: Cash Price	$26.40
Rate for Payer: Cash Price	$26.40
Rate for Payer: Priority Health Cigna Priority Health	$23.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$17.29
Rate for Payer: Priority Health Narrow Network	$17.29
Rate for Payer: Priority Health SBD	$17.29
Rate for Payer: UMR Bronson Commercial	$15.18

PR MEATOTOMY CUTTING MEATUS SPX EXCEPT INFANT

Professional

Both

$335.00

Service Code	HCPCS 53020
Min. Negotiated Rate	$61.13
Max. Negotiated Rate	$359.24
Rate for Payer: Aetna Commercial	$123.91
Rate for Payer: BCBS Complete	$64.19
Rate for Payer: BCBS Trust/PPO	$359.24
Rate for Payer: Cash Price	$268.00
Rate for Payer: Cash Price	$268.00
Rate for Payer: Meridian Medicaid	$64.19
Rate for Payer: Priority Health Choice Medicaid	$61.13
Rate for Payer: Priority Health Cigna Priority Health	$234.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$153.46
Rate for Payer: Priority Health Narrow Network	$153.46
Rate for Payer: Priority Health SBD	$153.46
Rate for Payer: UMR Bronson Commercial	$154.10

PR MEATOTOMY CUTTING MEATUS SPX INFANT

Professional

Both

$350.00

Service Code	HCPCS 53025
Min. Negotiated Rate	$43.67
Max. Negotiated Rate	$718.49
Rate for Payer: Aetna Commercial	$86.37
Rate for Payer: BCBS Complete	$45.85
Rate for Payer: BCBS Trust/PPO	$718.49
Rate for Payer: Cash Price	$280.00
Rate for Payer: Cash Price	$280.00
Rate for Payer: Meridian Medicaid	$45.85
Rate for Payer: Priority Health Choice Medicaid	$43.67
Rate for Payer: Priority Health Cigna Priority Health	$245.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$109.15
Rate for Payer: Priority Health Narrow Network	$109.15
Rate for Payer: Priority Health SBD	$109.15
Rate for Payer: UMR Bronson Commercial	$161.00

PR MEDIASTINOSCOPY INCL BIOPSIES WHEN PERFORMED

Professional

Both

$2,199.00

Service Code	HCPCS 39400
Min. Negotiated Rate	$879.60
Max. Negotiated Rate	$1,539.30
Rate for Payer: BCBS Complete	$879.60
Rate for Payer: Cash Price	$1,759.20
Rate for Payer: Priority Health Cigna Priority Health	$1,539.30
Rate for Payer: UMR Bronson Commercial	$1,011.54

PR MEDIASTINOSCOPY INCLUDES MEDIASTINAL MASS BIOPSY

Professional

Both

$951.00

Service Code	HCPCS 39401
Min. Negotiated Rate	$194.04
Max. Negotiated Rate	$665.70
Rate for Payer: Aetna Commercial	$314.80
Rate for Payer: BCBS Complete	$203.74
Rate for Payer: BCBS Trust/PPO	$207.62
Rate for Payer: Cash Price	$760.80
Rate for Payer: Cash Price	$760.80
Rate for Payer: Meridian Medicaid	$203.74
Rate for Payer: Priority Health Choice Medicaid	$194.04
Rate for Payer: Priority Health Cigna Priority Health	$665.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$481.96
Rate for Payer: Priority Health Narrow Network	$481.96
Rate for Payer: Priority Health SBD	$481.96
Rate for Payer: UMR Bronson Commercial	$437.46

PR MEDIASTINOSCOPY WITH LYMPH NODE BIOPSY/IES

Professional

Both

$828.00

Service Code	HCPCS 39402
Min. Negotiated Rate	$253.26
Max. Negotiated Rate	$629.31
Rate for Payer: Aetna Commercial	$412.59
Rate for Payer: BCBS Complete	$265.92
Rate for Payer: BCBS Trust/PPO	$487.62
Rate for Payer: Cash Price	$662.40
Rate for Payer: Cash Price	$662.40
Rate for Payer: Meridian Medicaid	$265.92
Rate for Payer: Priority Health Choice Medicaid	$253.26
Rate for Payer: Priority Health Cigna Priority Health	$579.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$629.31
Rate for Payer: Priority Health Narrow Network	$629.31
Rate for Payer: Priority Health SBD	$629.31
Rate for Payer: UMR Bronson Commercial	$380.88

PR MEDIAST W/EXPL DRG RMVL FB/BX CRV APPR

Professional

Both

$2,499.00

Service Code	HCPCS 39000
Min. Negotiated Rate	$322.70
Max. Negotiated Rate	$1,749.30
Rate for Payer: Aetna Commercial	$505.24
Rate for Payer: BCBS Complete	$338.84
Rate for Payer: BCBS Trust/PPO	$418.94
Rate for Payer: Cash Price	$1,999.20
Rate for Payer: Cash Price	$1,999.20
Rate for Payer: Meridian Medicaid	$338.84
Rate for Payer: Priority Health Choice Medicaid	$322.70
Rate for Payer: Priority Health Cigna Priority Health	$1,749.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$762.29
Rate for Payer: Priority Health Narrow Network	$762.29
Rate for Payer: Priority Health SBD	$762.29
Rate for Payer: UMR Bronson Commercial	$1,149.54

PR MEDIAST W/EXPL DRG RMVL FB/BX TTHRC APPR

Professional

Both

$5,144.00

Service Code	HCPCS 39010
Min. Negotiated Rate	$499.91
Max. Negotiated Rate	$3,600.80
Rate for Payer: Aetna Commercial	$804.81
Rate for Payer: BCBS Complete	$524.91
Rate for Payer: BCBS Trust/PPO	$1,750.26
Rate for Payer: Cash Price	$4,115.20
Rate for Payer: Cash Price	$4,115.20
Rate for Payer: Meridian Medicaid	$524.91
Rate for Payer: Priority Health Choice Medicaid	$499.91
Rate for Payer: Priority Health Cigna Priority Health	$3,600.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,238.92
Rate for Payer: Priority Health Narrow Network	$1,238.92
Rate for Payer: Priority Health SBD	$1,238.92
Rate for Payer: UMR Bronson Commercial	$2,366.24

PR MEDICAL NUTRITION ASSMT&IVNTJ INDIV EACH 15 MI

Professional

Both

$60.00

Service Code	HCPCS 97802
Min. Negotiated Rate	$24.00
Max. Negotiated Rate	$1,112.07
Rate for Payer: Aetna Commercial	$47.63
Rate for Payer: BCBS Complete	$24.00
Rate for Payer: BCBS Trust/PPO	$1,112.07
Rate for Payer: Cash Price	$48.00
Rate for Payer: Cash Price	$48.00
Rate for Payer: Priority Health Cigna Priority Health	$42.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$33.34
Rate for Payer: Priority Health Narrow Network	$33.34
Rate for Payer: Priority Health SBD	$33.34
Rate for Payer: UMR Bronson Commercial	$27.60

PR MEDICAL NUTRITION RE-ASSMT&IVNTJ INDIV EA 15 M

Professional

Both

$49.00

Service Code	HCPCS 97803
Min. Negotiated Rate	$19.60
Max. Negotiated Rate	$561.58
Rate for Payer: Aetna Commercial	$40.61
Rate for Payer: BCBS Complete	$19.60
Rate for Payer: BCBS Trust/PPO	$561.58
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: Priority Health HMO/PPO/Tiered Network	$29.82
Rate for Payer: Priority Health Narrow Network	$29.82
Rate for Payer: Priority Health SBD	$29.82
Rate for Payer: UMR Bronson Commercial	$22.54

PR MEDICAL NUTRITION THERAPY GRP2/ INDIV EA 30 MI

Professional

Both

$27.00

Service Code	HCPCS 97804
Min. Negotiated Rate	$10.80
Max. Negotiated Rate	$641.36
Rate for Payer: Aetna Commercial	$22.56
Rate for Payer: BCBS Complete	$10.80
Rate for Payer: BCBS Trust/PPO	$641.36
Rate for Payer: Cash Price	$21.60
Rate for Payer: Cash Price	$21.60
Rate for Payer: Priority Health Cigna Priority Health	$18.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$15.57
Rate for Payer: Priority Health Narrow Network	$15.57
Rate for Payer: Priority Health SBD	$15.57
Rate for Payer: UMR Bronson Commercial	$12.42

PR MEDICATION ADMIN & HEMODYNAMIC MEASURMENT

Professional

Both

$322.00

Service Code	HCPCS 93463
Min. Negotiated Rate	$60.92
Max. Negotiated Rate	$735.92
Rate for Payer: Aetna Commercial	$131.17
Rate for Payer: BCBS Complete	$63.97
Rate for Payer: BCBS Trust/PPO	$735.92
Rate for Payer: Cash Price	$257.60
Rate for Payer: Cash Price	$257.60
Rate for Payer: Meridian Medicaid	$63.97
Rate for Payer: Priority Health Choice Medicaid	$60.92
Rate for Payer: Priority Health Cigna Priority Health	$225.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$135.72
Rate for Payer: Priority Health Narrow Network	$135.72
Rate for Payer: Priority Health SBD	$135.72
Rate for Payer: UMR Bronson Commercial	$148.12

Know your out-of-pocket cost for care.

All Charges