Bronson Methodist Hospital

All Charges

Charge

Type

Setting

Price

PR MOD SED OTHER PHYS/QHP INITIAL 15 MINS <5 YRS

Professional

Both

$185.00

Service Code	HCPCS 99155
Min. Negotiated Rate	$52.19
Max. Negotiated Rate	$880.15
Rate for Payer: Aetna Commercial	$93.68
Rate for Payer: BCBS Complete	$54.80
Rate for Payer: BCBS Trust/PPO	$880.15
Rate for Payer: Cash Price	$148.00
Rate for Payer: Cash Price	$148.00
Rate for Payer: Meridian Medicaid	$54.80
Rate for Payer: Priority Health Choice Medicaid	$52.19
Rate for Payer: Priority Health Cigna Priority Health	$129.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$184.19
Rate for Payer: Priority Health Narrow Network	$184.19
Rate for Payer: Priority Health SBD	$184.19
Rate for Payer: UMR Bronson Commercial	$85.10

PR MOD SED OTHER PHYS/QHP INITIAL 15 MINS 5/> YRS

Professional

Both

$152.00

Service Code	HCPCS 99156
Min. Negotiated Rate	$47.29
Max. Negotiated Rate	$672.53
Rate for Payer: Aetna Commercial	$85.20
Rate for Payer: BCBS Complete	$49.65
Rate for Payer: BCBS Trust/PPO	$672.53
Rate for Payer: Cash Price	$121.60
Rate for Payer: Cash Price	$121.60
Rate for Payer: Meridian Medicaid	$49.65
Rate for Payer: Priority Health Choice Medicaid	$47.29
Rate for Payer: Priority Health Cigna Priority Health	$106.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$169.11
Rate for Payer: Priority Health Narrow Network	$169.11
Rate for Payer: Priority Health SBD	$169.11
Rate for Payer: UMR Bronson Commercial	$69.92

PR MOD SED SAME PHYS/QHP EACH ADDL 15 MINS

Professional

Both

$32.00

Service Code	HCPCS 99153
Min. Negotiated Rate	$11.06
Max. Negotiated Rate	$674.11
Rate for Payer: Aetna Commercial	$11.06
Rate for Payer: BCBS Complete	$12.80
Rate for Payer: BCBS Trust/PPO	$674.11
Rate for Payer: Cash Price	$25.60
Rate for Payer: Cash Price	$25.60
Rate for Payer: Priority Health Cigna Priority Health	$22.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$19.20
Rate for Payer: Priority Health Narrow Network	$19.20
Rate for Payer: Priority Health SBD	$19.20
Rate for Payer: UMR Bronson Commercial	$14.72

PR MOD SED SAME PHYS/QHP INITIAL 15 MINS <5 YRS

Professional

Both

$160.00

Service Code	HCPCS 99151
Min. Negotiated Rate	$15.12
Max. Negotiated Rate	$726.41
Rate for Payer: Aetna Commercial	$27.86
Rate for Payer: BCBS Complete	$15.88
Rate for Payer: BCBS Trust/PPO	$726.41
Rate for Payer: Cash Price	$128.00
Rate for Payer: Cash Price	$128.00
Rate for Payer: Meridian Medicaid	$15.88
Rate for Payer: Priority Health Choice Medicaid	$15.12
Rate for Payer: Priority Health Cigna Priority Health	$112.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$54.36
Rate for Payer: Priority Health Narrow Network	$54.36
Rate for Payer: Priority Health SBD	$54.36
Rate for Payer: UMR Bronson Commercial	$73.60

PR MOD SED SAME PHYS/QHP INITIAL 15 MINS 5/> YRS

Professional

Both

$152.00

Service Code	HCPCS 99152
Min. Negotiated Rate	$7.67
Max. Negotiated Rate	$552.07
Rate for Payer: Aetna Commercial	$13.74
Rate for Payer: BCBS Complete	$8.05
Rate for Payer: BCBS Trust/PPO	$552.07
Rate for Payer: Cash Price	$121.60
Rate for Payer: Cash Price	$121.60
Rate for Payer: Meridian Medicaid	$8.05
Rate for Payer: Priority Health Choice Medicaid	$7.67
Rate for Payer: Priority Health Cigna Priority Health	$106.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$39.51
Rate for Payer: Priority Health Narrow Network	$39.51
Rate for Payer: Priority Health SBD	$39.51
Rate for Payer: UMR Bronson Commercial	$69.92

PR MONALISA TOUCH, SERIES, UP TO 7 VISITS, LICHEN SCLEROSUS

Professional

Both

$2,100.00

Service Code	HCPCS 00560
Hospital Revenue Code	990
Min. Negotiated Rate	$840.00
Max. Negotiated Rate	$1,470.00
Rate for Payer: BCBS Complete	$840.00
Rate for Payer: Cash Price	$1,680.00
Rate for Payer: Priority Health Cigna Priority Health	$1,470.00
Rate for Payer: UMR Bronson Commercial	$966.00

PR MONOVISC INJ PER DOSE

Professional

Both

$923.00

Service Code	HCPCS J7327
Min. Negotiated Rate	$369.20
Max. Negotiated Rate	$735.80
Rate for Payer: Aetna Commercial	$735.80
Rate for Payer: BCBS Complete	$369.20
Rate for Payer: BCBS Trust/PPO	$727.84
Rate for Payer: Cash Price	$738.40
Rate for Payer: Cash Price	$738.40
Rate for Payer: Priority Health Cigna Priority Health	$646.10
Rate for Payer: UMR Bronson Commercial	$424.58

PR MORPHINE SULFATE INJECTION

Professional

Both

$8.00

Service Code	HCPCS J2270
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$5.60
Rate for Payer: Aetna Commercial	$4.80
Rate for Payer: BCBS Complete	$3.20
Rate for Payer: BCBS Trust/PPO	$0.09
Rate for Payer: Cash Price	$6.40
Rate for Payer: Cash Price	$6.40
Rate for Payer: Priority Health Cigna Priority Health	$5.60
Rate for Payer: UMR Bronson Commercial	$3.68

PR MOTOR &/SENS NRV CNDJ PRECONF ELTRD ARRAY LIMB

Professional

Both

$135.00

Service Code	HCPCS 95905
Min. Negotiated Rate	$3.59
Max. Negotiated Rate	$1,790.41
Rate for Payer: Aetna Commercial	$49.71
Rate for Payer: BCBS Complete	$54.00
Rate for Payer: BCBS Trust/PPO	$1,790.41
Rate for Payer: Cash Price	$108.00
Rate for Payer: Cash Price	$108.00
Rate for Payer: Priority Health Cigna Priority Health	$94.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$3.59
Rate for Payer: Priority Health Narrow Network	$3.59
Rate for Payer: Priority Health SBD	$46.26
Rate for Payer: UMR Bronson Commercial	$62.10

PR MPSV4 VACCINE GROUPS ACYW-135 SUBQ USE

Professional

Both

$126.00

Service Code	HCPCS 90733
Min. Negotiated Rate	$50.40
Max. Negotiated Rate	$125.50
Rate for Payer: Aetna Commercial	$125.50
Rate for Payer: BCBS Complete	$50.40
Rate for Payer: BCBS Trust/PPO	$125.49
Rate for Payer: Cash Price	$100.80
Rate for Payer: Cash Price	$100.80
Rate for Payer: Priority Health Cigna Priority Health	$88.20
Rate for Payer: UMR Bronson Commercial	$57.96

PR MULTIPLE FAM GROUP BHV TX GDN PHYS/QHP EA 15 MIN

Professional

Both

$60.00

Service Code	HCPCS 97157
Min. Negotiated Rate	$20.79
Max. Negotiated Rate	$997.43
Rate for Payer: Aetna Commercial	$20.79
Rate for Payer: BCBS Complete	$24.00
Rate for Payer: BCBS Trust/PPO	$997.43
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	$47.17
Rate for Payer: Priority Health Narrow Network	$47.17
Rate for Payer: Priority Health SBD	$47.17
Rate for Payer: UMR Bronson Commercial	$27.60

PR MULTIPLE FAMILY GROUP PSYCHOTHERAPY

Professional

Both

$90.00

Service Code	HCPCS 90849
Min. Negotiated Rate	$36.00
Max. Negotiated Rate	$63.00
Rate for Payer: Aetna Commercial	$46.80
Rate for Payer: BCBS Complete	$36.00
Rate for Payer: BCBS Trust/PPO	$58.11
Rate for Payer: Cash Price	$72.00
Rate for Payer: Cash Price	$72.00
Rate for Payer: Priority Health Cigna Priority Health	$63.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$38.14
Rate for Payer: Priority Health Narrow Network	$38.14
Rate for Payer: Priority Health SBD	$38.14
Rate for Payer: UMR Bronson Commercial	$41.40

PR MUSCLE-SKIN FLAP,HEAD/NECK

Professional

Both

$3,183.00

Service Code	HCPCS 15732
Min. Negotiated Rate	$1,273.20
Max. Negotiated Rate	$2,228.10
Rate for Payer: BCBS Complete	$1,273.20
Rate for Payer: Cash Price	$2,546.40
Rate for Payer: Priority Health Cigna Priority Health	$2,228.10
Rate for Payer: UMR Bronson Commercial	$1,464.18

PR MUSCLE/TENDON TRANSFER UPPER ARM/ELBOW SINGLE

Professional

Both

$1,118.00

Service Code	HCPCS 24301
Min. Negotiated Rate	$114.64
Max. Negotiated Rate	$1,159.18
Rate for Payer: Aetna Commercial	$1,002.27
Rate for Payer: BCBS Complete	$510.37
Rate for Payer: BCBS Trust/PPO	$114.64
Rate for Payer: Cash Price	$894.40
Rate for Payer: Cash Price	$894.40
Rate for Payer: Meridian Medicaid	$510.37
Rate for Payer: Priority Health Choice Medicaid	$486.07
Rate for Payer: Priority Health Cigna Priority Health	$782.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,159.18
Rate for Payer: Priority Health Narrow Network	$1,159.18
Rate for Payer: Priority Health SBD	$1,159.18
Rate for Payer: UMR Bronson Commercial	$514.28

PR MUSCLE TRANSFER SHOULDER/UPPER ARM MULTIPLE

Professional

Both

$3,005.00

Service Code	HCPCS 23397
Min. Negotiated Rate	$78.96
Max. Negotiated Rate	$2,103.50
Rate for Payer: Aetna Commercial	$1,512.60
Rate for Payer: BCBS Complete	$770.48
Rate for Payer: BCBS Trust/PPO	$78.96
Rate for Payer: Cash Price	$2,404.00
Rate for Payer: Cash Price	$2,404.00
Rate for Payer: Meridian Medicaid	$770.48
Rate for Payer: Priority Health Choice Medicaid	$733.79
Rate for Payer: Priority Health Cigna Priority Health	$2,103.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,743.36
Rate for Payer: Priority Health Narrow Network	$1,743.36
Rate for Payer: Priority Health SBD	$1,743.36
Rate for Payer: UMR Bronson Commercial	$1,382.30

PR MUSCLE TRANSFER SHOULDER/UPPER ARM SINGLE

Professional

Both

$3,347.00

Service Code	HCPCS 23395
Min. Negotiated Rate	$61.98
Max. Negotiated Rate	$2,342.90
Rate for Payer: Aetna Commercial	$1,710.89
Rate for Payer: BCBS Complete	$866.87
Rate for Payer: BCBS Trust/PPO	$61.98
Rate for Payer: Cash Price	$2,677.60
Rate for Payer: Cash Price	$2,677.60
Rate for Payer: Meridian Medicaid	$866.87
Rate for Payer: Priority Health Choice Medicaid	$825.59
Rate for Payer: Priority Health Cigna Priority Health	$2,342.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,959.87
Rate for Payer: Priority Health Narrow Network	$1,959.87
Rate for Payer: Priority Health SBD	$1,959.87
Rate for Payer: UMR Bronson Commercial	$1,539.62

PR MUSC MYOCUTANEOUS/FASCIOCUTANEOUS FLAP LXTR

Professional

Both

$2,426.00

Service Code	HCPCS 15738
Min. Negotiated Rate	$75.69
Max. Negotiated Rate	$1,698.20
Rate for Payer: Aetna Commercial	$1,391.76
Rate for Payer: BCBS Complete	$849.65
Rate for Payer: BCBS Trust/PPO	$75.69
Rate for Payer: Cash Price	$1,940.80
Rate for Payer: Cash Price	$1,940.80
Rate for Payer: Meridian Medicaid	$849.65
Rate for Payer: Priority Health Choice Medicaid	$809.19
Rate for Payer: Priority Health Cigna Priority Health	$1,698.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,556.61
Rate for Payer: Priority Health Narrow Network	$1,556.61
Rate for Payer: Priority Health SBD	$1,556.61
Rate for Payer: UMR Bronson Commercial	$1,115.96

PR MUSC MYOCUTANEOUS/FASCIOCUTANEOUS FLAP TRUNK

Facility

$4,510.00

Service Code	CPT 15734
Hospital Charge Code	15734
Min. Negotiated Rate	$1,473.82
Max. Negotiated Rate	$10,039.01
Rate for Payer: Aetna American Axle	$2,931.50
Rate for Payer: Aetna Commercial	$3,833.50
Rate for Payer: Aetna Medicare	$3,316.52
Rate for Payer: Aetna New Business (MI Preferred)	$2,931.50
Rate for Payer: Allen County Amish Medical Aid Commercial	$3,986.20
Rate for Payer: Amish Plain Church Group Commercial	$3,986.20
Rate for Payer: BCBS Complete	$1,831.74
Rate for Payer: BCBS MAPPO	$3,188.96
Rate for Payer: BCBS Trust/PPO	$2,344.98
Rate for Payer: BCN Medicare Advantage	$3,188.96
Rate for Payer: Cash Price	$3,608.00
Rate for Payer: Cash Price	$3,608.00
Rate for Payer: Cofinity Commercial	$3,157.00
Rate for Payer: Cofinity Commercial	$3,878.60
Rate for Payer: Encore Health Key Benefits Commercial	$3,608.00
Rate for Payer: Health Alliance Plan Medicare Advantage	$3,188.96
Rate for Payer: Healthscope Commercial	$4,059.00
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial	$3,157.00
Rate for Payer: Lakeland Regional Health Systems Commercial	$3,382.50
Rate for Payer: Mclaren Medicaid	$1,744.36
Rate for Payer: Mclaren Medicare	$3,188.96
Rate for Payer: Meridian Medicaid	$1,831.74
Rate for Payer: Meridian Wellcare - Medicare Advantage	$3,348.41
Rate for Payer: MI Amish Medical Board Commercial	$3,667.30
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$3,833.50
Rate for Payer: PACE Medicare	$3,029.51
Rate for Payer: PACE SWMI	$3,188.96
Rate for Payer: PHP Commercial	$3,833.50
Rate for Payer: PHP Medicare Advantage	$3,188.96
Rate for Payer: Priority Health Choice Medicaid	$1,744.36
Rate for Payer: Priority Health Cigna Priority Health	$3,157.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$10,039.01
Rate for Payer: Priority Health Medicare	$3,188.96
Rate for Payer: Priority Health Narrow Network	$8,031.21
Rate for Payer: Priority Health SBD	$2,841.30
Rate for Payer: Railroad Medicare Medicare	$3,188.96
Rate for Payer: UHC All Payor (Choice/PPO)	$1,621.20
Rate for Payer: UHC Dual Complete DSNP	$3,188.96
Rate for Payer: UHC Exchange	$1,473.82
Rate for Payer: UHC Medicare Advantage	$3,284.63
Rate for Payer: UMR Bronson Commercial	$1,668.70
Rate for Payer: VA VA	$3,188.96
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$3,382.50

PR MUSC MYOCUTANEOUS/FASCIOCUTANEOUS FLAP TRUNK

Professional

Both

$4,510.00

Service Code	HCPCS 15734
Min. Negotiated Rate	$75.69
Max. Negotiated Rate	$3,157.00
Rate for Payer: Aetna Commercial	$1,635.70
Rate for Payer: BCBS Complete	$1,006.65
Rate for Payer: BCBS Trust/PPO	$75.69
Rate for Payer: Cash Price	$3,608.00
Rate for Payer: Cash Price	$3,608.00
Rate for Payer: Meridian Medicaid	$1,006.65
Rate for Payer: Priority Health Choice Medicaid	$958.71
Rate for Payer: Priority Health Cigna Priority Health	$3,157.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,840.63
Rate for Payer: Priority Health Narrow Network	$1,840.63
Rate for Payer: Priority Health SBD	$1,840.63
Rate for Payer: UMR Bronson Commercial	$2,074.60

PR MUSC MYOCUTANEOUS/FASCIOCUTANEOUS FLAP TRUNK

Professional

Both

$4,510.00

Service Code	HCPCS 15734
Hospital Charge Code	15734
Min. Negotiated Rate	$75.69
Max. Negotiated Rate	$3,157.00
Rate for Payer: Aetna Commercial	$1,635.70
Rate for Payer: BCBS Complete	$1,006.65
Rate for Payer: BCBS Trust/PPO	$75.69
Rate for Payer: Cash Price	$3,608.00
Rate for Payer: Cash Price	$3,608.00
Rate for Payer: Meridian Medicaid	$1,006.65
Rate for Payer: Priority Health Choice Medicaid	$958.71
Rate for Payer: Priority Health Cigna Priority Health	$3,157.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,840.63
Rate for Payer: Priority Health Narrow Network	$1,840.63
Rate for Payer: Priority Health SBD	$1,840.63
Rate for Payer: UMR Bronson Commercial	$2,074.60

PR MUSC MYOCUTANEOUS/FASCIOCUTANEOUS FLAP TRUNK

Facility

$4,510.00

Service Code	CPT 15734
Hospital Charge Code	15734
Min. Negotiated Rate	$1,984.40
Max. Negotiated Rate	$4,059.00
Rate for Payer: Aetna American Axle	$2,931.50
Rate for Payer: Aetna Commercial	$3,833.50
Rate for Payer: Aetna New Business (MI Preferred)	$2,931.50
Rate for Payer: Cash Price	$3,608.00
Rate for Payer: Cofinity Commercial	$3,157.00
Rate for Payer: Cofinity Commercial	$3,878.60
Rate for Payer: Encore Health Key Benefits Commercial	$3,608.00
Rate for Payer: Healthscope Commercial	$4,059.00
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial	$3,157.00
Rate for Payer: Lakeland Regional Health Systems Commercial	$3,382.50
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$3,833.50
Rate for Payer: PHP Commercial	$3,833.50
Rate for Payer: Priority Health Cigna Priority Health	$3,157.00
Rate for Payer: Priority Health SBD	$2,841.30
Rate for Payer: UMR Bronson Commercial	$1,984.40
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$3,382.50

PR MUSC MYOCUTANEOUS/FASCIOCUTANEOUS FLAP UXTR

Professional

Both

$2,261.00

Service Code	HCPCS 15736
Min. Negotiated Rate	$778.94
Max. Negotiated Rate	$1,648.76
Rate for Payer: Aetna Commercial	$1,317.66
Rate for Payer: BCBS Complete	$817.89
Rate for Payer: BCBS Trust/PPO	$1,648.76
Rate for Payer: Cash Price	$1,808.80
Rate for Payer: Cash Price	$1,808.80
Rate for Payer: Meridian Medicaid	$817.89
Rate for Payer: Priority Health Choice Medicaid	$778.94
Rate for Payer: Priority Health Cigna Priority Health	$1,582.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,492.48
Rate for Payer: Priority Health Narrow Network	$1,492.48
Rate for Payer: Priority Health SBD	$1,492.48
Rate for Payer: UMR Bronson Commercial	$1,040.06

PR MUSC MYOQ/FSCQ FLAP HEAD&NECK W/NAMED VASC PEDCL

Professional

Both

$3,100.00

Service Code	HCPCS 15733
Min. Negotiated Rate	$657.11
Max. Negotiated Rate	$2,170.00
Rate for Payer: Aetna Commercial	$1,117.11
Rate for Payer: BCBS Complete	$689.97
Rate for Payer: BCBS Trust/PPO	$1,152.77
Rate for Payer: Cash Price	$2,480.00
Rate for Payer: Cash Price	$2,480.00
Rate for Payer: Meridian Medicaid	$689.97
Rate for Payer: Priority Health Choice Medicaid	$657.11
Rate for Payer: Priority Health Cigna Priority Health	$2,170.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,263.53
Rate for Payer: Priority Health Narrow Network	$1,263.53
Rate for Payer: Priority Health SBD	$1,263.53
Rate for Payer: UMR Bronson Commercial	$1,426.00

PR MYOCARDIAL RESECTION

Professional

Both

$6,145.00

Service Code	HCPCS 33542
Min. Negotiated Rate	$841.58
Max. Negotiated Rate	$4,301.50
Rate for Payer: Aetna Commercial	$3,532.04
Rate for Payer: BCBS Complete	$1,723.00
Rate for Payer: BCBS Trust/PPO	$841.58
Rate for Payer: Cash Price	$4,916.00
Rate for Payer: Cash Price	$4,916.00
Rate for Payer: Meridian Medicaid	$1,723.00
Rate for Payer: Priority Health Choice Medicaid	$1,640.95
Rate for Payer: Priority Health Cigna Priority Health	$4,301.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$4,087.02
Rate for Payer: Priority Health Narrow Network	$4,087.02
Rate for Payer: Priority Health SBD	$4,087.02
Rate for Payer: UMR Bronson Commercial	$2,826.70

PR MYOMECTOMY 1-4 MYOMAS 250 GM/< VAGINAL APPR

Professional

Both

$1,923.00

Service Code	HCPCS 58145
Min. Negotiated Rate	$366.79
Max. Negotiated Rate	$1,346.10
Rate for Payer: Aetna Commercial	$676.97
Rate for Payer: BCBS Complete	$385.13
Rate for Payer: BCBS Trust/PPO	$876.45
Rate for Payer: Cash Price	$1,538.40
Rate for Payer: Cash Price	$1,538.40
Rate for Payer: Meridian Medicaid	$385.13
Rate for Payer: Priority Health Choice Medicaid	$366.79
Rate for Payer: Priority Health Cigna Priority Health	$1,346.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$808.60
Rate for Payer: Priority Health Narrow Network	$808.60
Rate for Payer: Priority Health SBD	$808.60
Rate for Payer: UMR Bronson Commercial	$884.58

Know your out-of-pocket cost for care.

All Charges