Bronson Methodist Hospital

All Charges

Charge

Type

Setting

Price

PR MEDICATION THERAPY EACH ADDITIONAL 15 MIN

Professional

Both

$13.00

Service Code	HCPCS 99607
Min. Negotiated Rate	$5.20
Max. Negotiated Rate	$370.34
Rate for Payer: Aetna Commercial	$45.29
Rate for Payer: BCBS Complete	$5.20
Rate for Payer: BCBS Trust/PPO	$370.34
Rate for Payer: Cash Price	$10.40
Rate for Payer: Cash Price	$10.40
Rate for Payer: Priority Health Cigna Priority Health	$9.10
Rate for Payer: UMR Bronson Commercial	$5.98

PR MEDICATION THERAPY INITIAL 15 MIN ESTABLISHED PT

Professional

Both

$31.00

Service Code	HCPCS 99606
Min. Negotiated Rate	$12.40
Max. Negotiated Rate	$62.87
Rate for Payer: Aetna Commercial	$33.89
Rate for Payer: BCBS Complete	$12.40
Rate for Payer: BCBS Trust/PPO	$62.87
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 MEDICATION THERAPY INITIAL 15 MIN NEW PATIENT

Professional

Both

$63.00

Service Code	HCPCS 99605
Min. Negotiated Rate	$25.20
Max. Negotiated Rate	$79.81
Rate for Payer: Aetna Commercial	$67.55
Rate for Payer: BCBS Complete	$25.20
Rate for Payer: BCBS Trust/PPO	$79.81
Rate for Payer: Cash Price	$50.40
Rate for Payer: Cash Price	$50.40
Rate for Payer: Priority Health Cigna Priority Health	$44.10
Rate for Payer: UMR Bronson Commercial	$28.98

PR MEDROXYPROGESTERONE ACETATE

Professional

Both

$1.00

Service Code	HCPCS J1050
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.70
Rate for Payer: Aetna Commercial	$0.52
Rate for Payer: BCBS Complete	$0.40
Rate for Payer: BCBS Trust/PPO	$0.14
Rate for Payer: Cash Price	$0.80
Rate for Payer: Cash Price	$0.80
Rate for Payer: Priority Health Cigna Priority Health	$0.70
Rate for Payer: UMR Bronson Commercial	$0.46

PR MEDROXYPROGESTERONE INJ

Professional

Both

$30.00

Service Code	HCPCS J1051
Min. Negotiated Rate	$12.00
Max. Negotiated Rate	$21.00
Rate for Payer: BCBS Complete	$12.00
Rate for Payer: Cash Price	$24.00
Rate for Payer: Priority Health Cigna Priority Health	$21.00
Rate for Payer: UMR Bronson Commercial	$13.80

PR MEDRXYPROGESTER ACETATE INJ

Professional

Both

$80.00

Service Code	HCPCS J1055
Min. Negotiated Rate	$32.00
Max. Negotiated Rate	$56.00
Rate for Payer: BCBS Complete	$32.00
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 MENACWYD/MENACWY-CRM CONJ VACC GRPS ACWY IM USE

Professional

Both

$140.00

Service Code	HCPCS 90734
Min. Negotiated Rate	$56.00
Max. Negotiated Rate	$151.33
Rate for Payer: Aetna Commercial	$151.33
Rate for Payer: BCBS Complete	$56.00
Rate for Payer: BCBS Trust/PPO	$150.00
Rate for Payer: Cash Price	$112.00
Rate for Payer: Cash Price	$112.00
Rate for Payer: Priority Health Cigna Priority Health	$98.00
Rate for Payer: UMR Bronson Commercial	$64.40

PR MENACWY-TT CONJ VACC SEROGROUPS ACWY FOR IM USE

Professional

Both

$180.00

Service Code	HCPCS 90619
Min. Negotiated Rate	$72.00
Max. Negotiated Rate	$168.36
Rate for Payer: Aetna Commercial	$159.10
Rate for Payer: BCBS Complete	$72.00
Rate for Payer: BCBS Trust/PPO	$168.36
Rate for Payer: Cash Price	$144.00
Rate for Payer: Cash Price	$144.00
Rate for Payer: Priority Health Cigna Priority Health	$126.00
Rate for Payer: UMR Bronson Commercial	$82.80

PR MENB-4C RECOMBNT PROT & OUTER MEMB VESIC VACC IM

Professional

Both

$232.00

Service Code	HCPCS 90620
Min. Negotiated Rate	$92.80
Max. Negotiated Rate	$215.42
Rate for Payer: Aetna Commercial	$215.42
Rate for Payer: BCBS Complete	$92.80
Rate for Payer: BCBS Trust/PPO	$198.55
Rate for Payer: Cash Price	$185.60
Rate for Payer: Cash Price	$185.60
Rate for Payer: Priority Health Cigna Priority Health	$162.40
Rate for Payer: UMR Bronson Commercial	$106.72

PR MENB-FHBP RECOMBNT LIPOPROTEIN VACC 2/3 DOSE IM

Professional

Both

$180.00

Service Code	HCPCS 90621
Min. Negotiated Rate	$72.00
Max. Negotiated Rate	$183.17
Rate for Payer: Aetna Commercial	$183.17
Rate for Payer: BCBS Complete	$72.00
Rate for Payer: BCBS Trust/PPO	$165.84
Rate for Payer: Cash Price	$144.00
Rate for Payer: Cash Price	$144.00
Rate for Payer: Priority Health Cigna Priority Health	$126.00
Rate for Payer: UMR Bronson Commercial	$82.80

PR MEPERIDINE HYDROCHL /100 MG

Professional

Both

$10.00

Service Code	HCPCS J2175
Min. Negotiated Rate	$1.87
Max. Negotiated Rate	$7.52
Rate for Payer: Aetna Commercial	$7.52
Rate for Payer: BCBS Complete	$4.00
Rate for Payer: BCBS Trust/PPO	$1.87
Rate for Payer: Cash Price	$8.00
Rate for Payer: Cash Price	$8.00
Rate for Payer: Priority Health Cigna Priority Health	$7.00
Rate for Payer: UMR Bronson Commercial	$4.60

PR MEPERIDINE/PROMETHAZINE INJ

Professional

Both

$11.00

Service Code	HCPCS J2180
Min. Negotiated Rate	$4.40
Max. Negotiated Rate	$7.70
Rate for Payer: Aetna Commercial	$7.58
Rate for Payer: BCBS Complete	$4.40
Rate for Payer: Cash Price	$8.80
Rate for Payer: Cash Price	$8.80
Rate for Payer: Priority Health Cigna Priority Health	$7.70
Rate for Payer: UMR Bronson Commercial	$5.06

PR METATARSECTOMY

Professional

Both

$1,050.00

Service Code	HCPCS 28140
Min. Negotiated Rate	$273.49
Max. Negotiated Rate	$1,034.26
Rate for Payer: Aetna Commercial	$575.34
Rate for Payer: BCBS Complete	$287.16
Rate for Payer: BCBS Trust/PPO	$1,034.26
Rate for Payer: Cash Price	$840.00
Rate for Payer: Cash Price	$840.00
Rate for Payer: Meridian Medicaid	$287.16
Rate for Payer: Priority Health Choice Medicaid	$273.49
Rate for Payer: Priority Health Cigna Priority Health	$735.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$650.05
Rate for Payer: Priority Health Narrow Network	$650.05
Rate for Payer: Priority Health SBD	$650.05
Rate for Payer: UMR Bronson Commercial	$483.00

PR METHYLPREDNISOLONE 20 MG INJ

Professional

Both

$10.00

Service Code	HCPCS J1020
Min. Negotiated Rate	$1.79
Max. Negotiated Rate	$7.25
Rate for Payer: Aetna Commercial	$7.25
Rate for Payer: BCBS Complete	$4.00
Rate for Payer: BCBS Trust/PPO	$1.79
Rate for Payer: Cash Price	$8.00
Rate for Payer: Cash Price	$8.00
Rate for Payer: Priority Health Cigna Priority Health	$7.00
Rate for Payer: UMR Bronson Commercial	$4.60

PR METHYLPREDNISOLONE 40 MG INJ

Professional

Both

$15.00

Service Code	HCPCS J1030
Min. Negotiated Rate	$3.27
Max. Negotiated Rate	$10.50
Rate for Payer: Aetna Commercial	$6.61
Rate for Payer: BCBS Complete	$6.00
Rate for Payer: BCBS Trust/PPO	$3.27
Rate for Payer: Cash Price	$12.00
Rate for Payer: Cash Price	$12.00
Rate for Payer: Priority Health Cigna Priority Health	$10.50
Rate for Payer: UMR Bronson Commercial	$6.90

PR METHYLPREDNISOLONE 80 MG INJ

Professional

Both

$25.00

Service Code	HCPCS J1040
Min. Negotiated Rate	$5.37
Max. Negotiated Rate	$17.50
Rate for Payer: Aetna Commercial	$10.10
Rate for Payer: BCBS Complete	$10.00
Rate for Payer: BCBS Trust/PPO	$5.37
Rate for Payer: Cash Price	$20.00
Rate for Payer: Cash Price	$20.00
Rate for Payer: Priority Health Cigna Priority Health	$17.50
Rate for Payer: UMR Bronson Commercial	$11.50

PR METHYLPREDNISOLONE INJECTION

Professional

Both

$10.00

Service Code	HCPCS J2920
Min. Negotiated Rate	$3.17
Max. Negotiated Rate	$7.00
Rate for Payer: Aetna Commercial	$4.31
Rate for Payer: BCBS Complete	$4.00
Rate for Payer: BCBS Trust/PPO	$3.17
Rate for Payer: Cash Price	$8.00
Rate for Payer: Cash Price	$8.00
Rate for Payer: Priority Health Cigna Priority Health	$7.00
Rate for Payer: UMR Bronson Commercial	$4.60

PR METHYLPREDNISOLONE INJECTION

Professional

Both

$25.00

Service Code	HCPCS J2930
Min. Negotiated Rate	$3.00
Max. Negotiated Rate	$17.50
Rate for Payer: Aetna Commercial	$6.06
Rate for Payer: BCBS Complete	$10.00
Rate for Payer: BCBS Trust/PPO	$3.00
Rate for Payer: Cash Price	$20.00
Rate for Payer: Cash Price	$20.00
Rate for Payer: Priority Health Cigna Priority Health	$17.50
Rate for Payer: UMR Bronson Commercial	$11.50

PR MGMT LVR HEMRRG CPLX SUTR WND/INJ

Professional

Both

$3,386.00

Service Code	HCPCS 47360
Min. Negotiated Rate	$331.24
Max. Negotiated Rate	$3,287.35
Rate for Payer: Aetna Commercial	$2,542.61
Rate for Payer: BCBS Complete	$1,254.68
Rate for Payer: BCBS Trust/PPO	$331.24
Rate for Payer: Cash Price	$2,708.80
Rate for Payer: Cash Price	$2,708.80
Rate for Payer: Meridian Medicaid	$1,254.68
Rate for Payer: Priority Health Choice Medicaid	$1,194.93
Rate for Payer: Priority Health Cigna Priority Health	$2,370.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$3,287.35
Rate for Payer: Priority Health Narrow Network	$3,287.35
Rate for Payer: Priority Health SBD	$3,287.35
Rate for Payer: UMR Bronson Commercial	$1,557.56

PR MGMT LVR HEMRRG SMPL SUTR LVR WND/INJ

Professional

Both

$2,846.00

Service Code	HCPCS 47350
Min. Negotiated Rate	$870.32
Max. Negotiated Rate	$2,400.11
Rate for Payer: Aetna Commercial	$1,849.58
Rate for Payer: BCBS Complete	$913.84
Rate for Payer: BCBS Trust/PPO	$1,888.67
Rate for Payer: Cash Price	$2,276.80
Rate for Payer: Cash Price	$2,276.80
Rate for Payer: Meridian Medicaid	$913.84
Rate for Payer: Priority Health Choice Medicaid	$870.32
Rate for Payer: Priority Health Cigna Priority Health	$1,992.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,400.11
Rate for Payer: Priority Health Narrow Network	$2,400.11
Rate for Payer: Priority Health SBD	$2,400.11
Rate for Payer: UMR Bronson Commercial	$1,309.16

PR MH PARTIAL HOSP TX UNDER 24H

Professional

Both

$254.00

Service Code	HCPCS H0035
Min. Negotiated Rate	$101.60
Max. Negotiated Rate	$268.86
Rate for Payer: Aetna Commercial	$268.86
Rate for Payer: BCBS Complete	$101.60
Rate for Payer: Cash Price	$203.20
Rate for Payer: Cash Price	$203.20
Rate for Payer: Priority Health Cigna Priority Health	$177.80
Rate for Payer: UMR Bronson Commercial	$116.84

PR MICRONEEDLING PIN ADB/THIGHS/BACK

Professional

Both

$450.00

Service Code	HCPCS 00108
Hospital Revenue Code	990
Min. Negotiated Rate	$180.00
Max. Negotiated Rate	$315.00
Rate for Payer: BCBS Complete	$180.00
Rate for Payer: Cash Price	$360.00
Rate for Payer: Priority Health Cigna Priority Health	$315.00
Rate for Payer: UMR Bronson Commercial	$207.00

PR MICRONEEDLING PIN FULL FACE

Professional

Both

$400.00

Service Code	HCPCS 00105
Hospital Revenue Code	990
Min. Negotiated Rate	$160.00
Max. Negotiated Rate	$280.00
Rate for Payer: BCBS Complete	$160.00
Rate for Payer: Cash Price	$320.00
Rate for Payer: Priority Health Cigna Priority Health	$280.00
Rate for Payer: UMR Bronson Commercial	$184.00

PR MICRONEEDLING PIN NECK

Professional

Both

$150.00

Service Code	HCPCS 00107
Hospital Revenue Code	990
Min. Negotiated Rate	$60.00
Max. Negotiated Rate	$105.00
Rate for Payer: BCBS Complete	$60.00
Rate for Payer: Cash Price	$120.00
Rate for Payer: Priority Health Cigna Priority Health	$105.00
Rate for Payer: UMR Bronson Commercial	$69.00

PR MICRONEEDLING PIN UPPER OR LOWER FACE

Professional

Both

$250.00

Service Code	HCPCS 00106
Hospital Revenue Code	990
Min. Negotiated Rate	$100.00
Max. Negotiated Rate	$175.00
Rate for Payer: BCBS Complete	$100.00
Rate for Payer: Cash Price	$200.00
Rate for Payer: Priority Health Cigna Priority Health	$175.00
Rate for Payer: UMR Bronson Commercial	$115.00

Know your out-of-pocket cost for care.

All Charges