Bronson Methodist Hospital

All Charges

Charge

Type

Setting

Price

PR MYOMECTOMY 1-4 MYOMAS W/250 GM/< ABDOMINAL APPR

Professional

Both

$2,974.00

Service Code	HCPCS 58140
Min. Negotiated Rate	$591.71
Max. Negotiated Rate	$2,081.80
Rate for Payer: Aetna Commercial	$1,116.00
Rate for Payer: BCBS Complete	$621.30
Rate for Payer: BCBS Trust/PPO	$737.51
Rate for Payer: Cash Price	$2,379.20
Rate for Payer: Cash Price	$2,379.20
Rate for Payer: Meridian Medicaid	$621.30
Rate for Payer: Priority Health Choice Medicaid	$591.71
Rate for Payer: Priority Health Cigna Priority Health	$2,081.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,327.49
Rate for Payer: Priority Health Narrow Network	$1,327.49
Rate for Payer: Priority Health SBD	$1,327.49
Rate for Payer: UMR Bronson Commercial	$1,368.04

PR MYOMECTOMY 5/> MYOMAS &/>250 GM ABDOMINA

Professional

Both

$2,172.00

Service Code	HCPCS 58146
Min. Negotiated Rate	$740.18
Max. Negotiated Rate	$2,587.61
Rate for Payer: Aetna Commercial	$1,387.27
Rate for Payer: BCBS Complete	$777.19
Rate for Payer: BCBS Trust/PPO	$2,587.61
Rate for Payer: Cash Price	$1,737.60
Rate for Payer: Cash Price	$1,737.60
Rate for Payer: Meridian Medicaid	$777.19
Rate for Payer: Priority Health Choice Medicaid	$740.18
Rate for Payer: Priority Health Cigna Priority Health	$1,520.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,639.94
Rate for Payer: Priority Health Narrow Network	$1,639.94
Rate for Payer: Priority Health SBD	$1,639.94
Rate for Payer: UMR Bronson Commercial	$999.12

PR MYRINGOPLASTY

Professional

Both

$1,144.00

Service Code	HCPCS 69620
Min. Negotiated Rate	$318.86
Max. Negotiated Rate	$1,611.84
Rate for Payer: Aetna Commercial	$551.61
Rate for Payer: BCBS Complete	$334.80
Rate for Payer: BCBS Trust/PPO	$1,611.84
Rate for Payer: Cash Price	$915.20
Rate for Payer: Cash Price	$915.20
Rate for Payer: Meridian Medicaid	$334.80
Rate for Payer: Priority Health Choice Medicaid	$318.86
Rate for Payer: Priority Health Cigna Priority Health	$800.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$703.42
Rate for Payer: Priority Health Narrow Network	$703.42
Rate for Payer: Priority Health SBD	$703.42
Rate for Payer: UMR Bronson Commercial	$526.24

PR MYRINGOTOMY ASPIR&/EUSTACHIAN TUBE NFLTJ

Professional

Both

$311.00

Service Code	HCPCS 69420
Min. Negotiated Rate	$77.96
Max. Negotiated Rate	$2,402.18
Rate for Payer: Aetna Commercial	$133.05
Rate for Payer: BCBS Complete	$81.86
Rate for Payer: BCBS Trust/PPO	$2,402.18
Rate for Payer: Cash Price	$248.80
Rate for Payer: Cash Price	$248.80
Rate for Payer: Meridian Medicaid	$81.86
Rate for Payer: Priority Health Choice Medicaid	$77.96
Rate for Payer: Priority Health Cigna Priority Health	$217.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$170.67
Rate for Payer: Priority Health Narrow Network	$170.67
Rate for Payer: Priority Health SBD	$170.67
Rate for Payer: UMR Bronson Commercial	$143.06

PR MYRINGOTOMY ASPIR&/EUSTACHIAN TUBE NFLTJ ANES

Professional

Both

$463.00

Service Code	HCPCS 69421
Min. Negotiated Rate	$97.77
Max. Negotiated Rate	$324.10
Rate for Payer: Aetna Commercial	$167.15
Rate for Payer: BCBS Complete	$102.66
Rate for Payer: BCBS Trust/PPO	$178.04
Rate for Payer: Cash Price	$370.40
Rate for Payer: Cash Price	$370.40
Rate for Payer: Meridian Medicaid	$102.66
Rate for Payer: Priority Health Choice Medicaid	$97.77
Rate for Payer: Priority Health Cigna Priority Health	$324.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$215.92
Rate for Payer: Priority Health Narrow Network	$215.92
Rate for Payer: Priority Health SBD	$215.92
Rate for Payer: UMR Bronson Commercial	$212.98

PR NALTREXONE, DEPOT FORM

Professional

Both

$4.00

Service Code	HCPCS J2315
Min. Negotiated Rate	$1.60
Max. Negotiated Rate	$4.08
Rate for Payer: Aetna Commercial	$4.08
Rate for Payer: BCBS Complete	$1.60
Rate for Payer: BCBS Trust/PPO	$4.03
Rate for Payer: Cash Price	$3.20
Rate for Payer: Cash Price	$3.20
Rate for Payer: Priority Health Cigna Priority Health	$2.80
Rate for Payer: UMR Bronson Commercial	$1.84

PR NASAL ENDOSCOPY DIAGNOSTIC UNI/BI SPX

Professional

Both

$308.00

Service Code	HCPCS 31231
Min. Negotiated Rate	$41.11
Max. Negotiated Rate	$698.94
Rate for Payer: Aetna Commercial	$81.77
Rate for Payer: BCBS Complete	$43.17
Rate for Payer: BCBS Trust/PPO	$698.94
Rate for Payer: Cash Price	$246.40
Rate for Payer: Cash Price	$246.40
Rate for Payer: Meridian Medicaid	$43.17
Rate for Payer: Priority Health Choice Medicaid	$41.11
Rate for Payer: Priority Health Cigna Priority Health	$215.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$86.12
Rate for Payer: Priority Health Narrow Network	$86.12
Rate for Payer: Priority Health SBD	$86.12
Rate for Payer: UMR Bronson Commercial	$141.68

PR NASAL/SINUS ENDOSCOPY DX MAXILLARY SINUSOSCOPY

Professional

Both

$507.00

Service Code	HCPCS 31233
Min. Negotiated Rate	$86.48
Max. Negotiated Rate	$844.75
Rate for Payer: Aetna Commercial	$170.89
Rate for Payer: BCBS Complete	$90.80
Rate for Payer: BCBS Trust/PPO	$844.75
Rate for Payer: Cash Price	$405.60
Rate for Payer: Cash Price	$405.60
Rate for Payer: Meridian Medicaid	$90.80
Rate for Payer: Priority Health Choice Medicaid	$86.48
Rate for Payer: Priority Health Cigna Priority Health	$354.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$186.15
Rate for Payer: Priority Health Narrow Network	$186.15
Rate for Payer: Priority Health SBD	$186.15
Rate for Payer: UMR Bronson Commercial	$233.22

PR NASAL/SINUS ENDOSCOPY DX SPHENOID SINUSOSCOPY

Professional

Both

$497.00

Service Code	HCPCS 31235
Min. Negotiated Rate	$101.81
Max. Negotiated Rate	$1,103.09
Rate for Payer: Aetna Commercial	$199.96
Rate for Payer: BCBS Complete	$106.90
Rate for Payer: BCBS Trust/PPO	$1,103.09
Rate for Payer: Cash Price	$397.60
Rate for Payer: Cash Price	$397.60
Rate for Payer: Meridian Medicaid	$106.90
Rate for Payer: Priority Health Choice Medicaid	$101.81
Rate for Payer: Priority Health Cigna Priority Health	$347.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$219.03
Rate for Payer: Priority Health Narrow Network	$219.03
Rate for Payer: Priority Health SBD	$219.03
Rate for Payer: UMR Bronson Commercial	$228.62

PR NASAL/SINUS ENDOSCOPY W/MAXILLARY ANTROSTOMY

Professional

Both

$530.00

Service Code	HCPCS 31256
Min. Negotiated Rate	$114.38
Max. Negotiated Rate	$1,413.73
Rate for Payer: Aetna Commercial	$229.59
Rate for Payer: BCBS Complete	$120.10
Rate for Payer: BCBS Trust/PPO	$1,413.73
Rate for Payer: Cash Price	$424.00
Rate for Payer: Cash Price	$424.00
Rate for Payer: Meridian Medicaid	$120.10
Rate for Payer: Priority Health Choice Medicaid	$114.38
Rate for Payer: Priority Health Cigna Priority Health	$371.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$248.20
Rate for Payer: Priority Health Narrow Network	$248.20
Rate for Payer: Priority Health SBD	$248.20
Rate for Payer: UMR Bronson Commercial	$243.80

PR NASAL/SINUS ENDOSCOPY W/SPHENOIDOTOMY

Professional

Both

$872.00

Service Code	HCPCS 31287
Min. Negotiated Rate	$127.80
Max. Negotiated Rate	$1,608.67
Rate for Payer: Aetna Commercial	$256.12
Rate for Payer: BCBS Complete	$134.19
Rate for Payer: BCBS Trust/PPO	$1,608.67
Rate for Payer: Cash Price	$697.60
Rate for Payer: Cash Price	$697.60
Rate for Payer: Meridian Medicaid	$134.19
Rate for Payer: Priority Health Choice Medicaid	$127.80
Rate for Payer: Priority Health Cigna Priority Health	$610.40
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	$401.12

PR NASAL/SINUS NDSC RPR CEREBRSP FLUID LEAK ETHMOID

Professional

Both

$2,069.00

Service Code	HCPCS 31290
Min. Negotiated Rate	$729.31
Max. Negotiated Rate	$1,586.40
Rate for Payer: Aetna Commercial	$1,463.14
Rate for Payer: BCBS Complete	$765.78
Rate for Payer: BCBS Trust/PPO	$1,225.13
Rate for Payer: Cash Price	$1,655.20
Rate for Payer: Cash Price	$1,655.20
Rate for Payer: Meridian Medicaid	$765.78
Rate for Payer: Priority Health Choice Medicaid	$729.31
Rate for Payer: Priority Health Cigna Priority Health	$1,448.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,586.40
Rate for Payer: Priority Health Narrow Network	$1,586.40
Rate for Payer: Priority Health SBD	$1,586.40
Rate for Payer: UMR Bronson Commercial	$951.74

PR NASAL/SINUS NDSC RPR CEREBSP FLUID LEAK SPHENOID

Professional

Both

$2,273.00

Service Code	HCPCS 31291
Min. Negotiated Rate	$782.35
Max. Negotiated Rate	$1,687.80
Rate for Payer: Aetna Commercial	$1,549.71
Rate for Payer: BCBS Complete	$821.47
Rate for Payer: BCBS Trust/PPO	$1,581.20
Rate for Payer: Cash Price	$1,818.40
Rate for Payer: Cash Price	$1,818.40
Rate for Payer: Meridian Medicaid	$821.47
Rate for Payer: Priority Health Choice Medicaid	$782.35
Rate for Payer: Priority Health Cigna Priority Health	$1,591.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,687.80
Rate for Payer: Priority Health Narrow Network	$1,687.80
Rate for Payer: Priority Health SBD	$1,687.80
Rate for Payer: UMR Bronson Commercial	$1,045.58

PR NASAL/SINUS NDSC SURG MEDIAL/INF ORB WALL DCMPRN

Professional

Both

$2,015.00

Service Code	HCPCS 31292
Min. Negotiated Rate	$631.97
Max. Negotiated Rate	$1,608.67
Rate for Payer: Aetna Commercial	$1,268.54
Rate for Payer: BCBS Complete	$663.57
Rate for Payer: BCBS Trust/PPO	$1,608.67
Rate for Payer: Cash Price	$1,612.00
Rate for Payer: Cash Price	$1,612.00
Rate for Payer: Meridian Medicaid	$663.57
Rate for Payer: Priority Health Choice Medicaid	$631.97
Rate for Payer: Priority Health Cigna Priority Health	$1,410.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,378.95
Rate for Payer: Priority Health Narrow Network	$1,378.95
Rate for Payer: Priority Health SBD	$1,378.95
Rate for Payer: UMR Bronson Commercial	$926.90

PR NASAL/SINUS NDSC SURG W/BX POLYPECT/DBRDMT SPX

Professional

Both

$579.00

Service Code	HCPCS 31237
Min. Negotiated Rate	$102.03
Max. Negotiated Rate	$1,028.07
Rate for Payer: Aetna Commercial	$202.11
Rate for Payer: BCBS Complete	$107.13
Rate for Payer: BCBS Trust/PPO	$1,028.07
Rate for Payer: Cash Price	$463.20
Rate for Payer: Cash Price	$463.20
Rate for Payer: Meridian Medicaid	$107.13
Rate for Payer: Priority Health Choice Medicaid	$102.03
Rate for Payer: Priority Health Cigna Priority Health	$405.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$220.41
Rate for Payer: Priority Health Narrow Network	$220.41
Rate for Payer: Priority Health SBD	$220.41
Rate for Payer: UMR Bronson Commercial	$266.34

PR NASAL/SINUS NDSC SURG W/CONCHA BULLOSA RESECTION

Professional

Both

$507.00

Service Code	HCPCS 31240
Min. Negotiated Rate	$101.39
Max. Negotiated Rate	$1,226.18
Rate for Payer: Aetna Commercial	$201.32
Rate for Payer: BCBS Complete	$106.46
Rate for Payer: BCBS Trust/PPO	$1,226.18
Rate for Payer: Cash Price	$405.60
Rate for Payer: Cash Price	$405.60
Rate for Payer: Meridian Medicaid	$106.46
Rate for Payer: Priority Health Choice Medicaid	$101.39
Rate for Payer: Priority Health Cigna Priority Health	$354.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$219.03
Rate for Payer: Priority Health Narrow Network	$219.03
Rate for Payer: Priority Health SBD	$219.03
Rate for Payer: UMR Bronson Commercial	$233.22

PR NASAL/SINUS NDSC SURG W/CONTROL NASAL HEMRRG

Professional

Both

$635.00

Service Code	HCPCS 31238
Min. Negotiated Rate	$106.71
Max. Negotiated Rate	$993.73
Rate for Payer: Aetna Commercial	$211.83
Rate for Payer: BCBS Complete	$112.05
Rate for Payer: BCBS Trust/PPO	$993.73
Rate for Payer: Cash Price	$508.00
Rate for Payer: Cash Price	$508.00
Rate for Payer: Meridian Medicaid	$112.05
Rate for Payer: Priority Health Choice Medicaid	$106.71
Rate for Payer: Priority Health Cigna Priority Health	$444.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$230.13
Rate for Payer: Priority Health Narrow Network	$230.13
Rate for Payer: Priority Health SBD	$230.13
Rate for Payer: UMR Bronson Commercial	$292.10

PR NASAL/SINUS NDSC SURG W/DACRYOCSTORHINOSTOMY

Professional

Both

$1,306.00

Service Code	HCPCS 31239
Min. Negotiated Rate	$387.23
Max. Negotiated Rate	$1,144.83
Rate for Payer: Aetna Commercial	$773.69
Rate for Payer: BCBS Complete	$406.59
Rate for Payer: BCBS Trust/PPO	$1,144.83
Rate for Payer: Cash Price	$1,044.80
Rate for Payer: Cash Price	$1,044.80
Rate for Payer: Meridian Medicaid	$406.59
Rate for Payer: Priority Health Choice Medicaid	$387.23
Rate for Payer: Priority Health Cigna Priority Health	$914.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$837.18
Rate for Payer: Priority Health Narrow Network	$837.18
Rate for Payer: Priority Health SBD	$837.18
Rate for Payer: UMR Bronson Commercial	$600.76

PR NASAL/SINUS NDSC SURG W/DILATION FRONTAL SINUS

Professional

Both

$560.00

Service Code	HCPCS 31296
Min. Negotiated Rate	$113.96
Max. Negotiated Rate	$1,248.37
Rate for Payer: Aetna Commercial	$228.73
Rate for Payer: BCBS Complete	$119.66
Rate for Payer: BCBS Trust/PPO	$1,248.37
Rate for Payer: Cash Price	$448.00
Rate for Payer: Cash Price	$448.00
Rate for Payer: Meridian Medicaid	$119.66
Rate for Payer: Priority Health Choice Medicaid	$113.96
Rate for Payer: Priority Health Cigna Priority Health	$392.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$247.27
Rate for Payer: Priority Health Narrow Network	$247.27
Rate for Payer: Priority Health SBD	$247.27
Rate for Payer: UMR Bronson Commercial	$257.60

PR NASAL/SINUS NDSC SURG W/DILATION MAXILLARY SINUS

Professional

Both

$3,915.00

Service Code	HCPCS 31295
Min. Negotiated Rate	$100.32
Max. Negotiated Rate	$2,740.50
Rate for Payer: Aetna Commercial	$200.89
Rate for Payer: BCBS Complete	$105.34
Rate for Payer: BCBS Trust/PPO	$1,788.82
Rate for Payer: Cash Price	$3,132.00
Rate for Payer: Cash Price	$3,132.00
Rate for Payer: Meridian Medicaid	$105.34
Rate for Payer: Priority Health Choice Medicaid	$100.32
Rate for Payer: Priority Health Cigna Priority Health	$2,740.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$217.17
Rate for Payer: Priority Health Narrow Network	$217.17
Rate for Payer: Priority Health SBD	$217.17
Rate for Payer: UMR Bronson Commercial	$1,800.90

PR NASAL/SINUS NDSC SURG W/DILATION SPHENOID SINUS

Professional

Both

$3,208.00

Service Code	HCPCS 31297
Min. Negotiated Rate	$91.59
Max. Negotiated Rate	$2,245.60
Rate for Payer: Aetna Commercial	$182.81
Rate for Payer: BCBS Complete	$96.17
Rate for Payer: BCBS Trust/PPO	$1,278.49
Rate for Payer: Cash Price	$2,566.40
Rate for Payer: Cash Price	$2,566.40
Rate for Payer: Meridian Medicaid	$96.17
Rate for Payer: Priority Health Choice Medicaid	$91.59
Rate for Payer: Priority Health Cigna Priority Health	$2,245.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$198.19
Rate for Payer: Priority Health Narrow Network	$198.19
Rate for Payer: Priority Health SBD	$198.19
Rate for Payer: UMR Bronson Commercial	$1,475.68

PR NASAL/SINUS NDSC TOTAL WITH SPHENOIDOTOMY

Professional

Both

$902.00

Service Code	HCPCS 31257
Min. Negotiated Rate	$282.86
Max. Negotiated Rate	$1,077.73
Rate for Payer: Aetna Commercial	$570.01
Rate for Payer: BCBS Complete	$297.00
Rate for Payer: BCBS Trust/PPO	$1,077.73
Rate for Payer: Cash Price	$721.60
Rate for Payer: Cash Price	$721.60
Rate for Payer: Meridian Medicaid	$297.00
Rate for Payer: Priority Health Choice Medicaid	$282.86
Rate for Payer: Priority Health Cigna Priority Health	$631.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$613.54
Rate for Payer: Priority Health Narrow Network	$613.54
Rate for Payer: Priority Health SBD	$613.54
Rate for Payer: UMR Bronson Commercial	$414.92

PR NASAL/SINUS NDSC TOT W/FRNT SINS EXPL TISS RMVL

Professional

Both

$999.00

Service Code	HCPCS 31253
Min. Negotiated Rate	$316.94
Max. Negotiated Rate	$1,572.75
Rate for Payer: Aetna Commercial	$639.80
Rate for Payer: BCBS Complete	$332.79
Rate for Payer: BCBS Trust/PPO	$1,572.75
Rate for Payer: Cash Price	$799.20
Rate for Payer: Cash Price	$799.20
Rate for Payer: Meridian Medicaid	$332.79
Rate for Payer: Priority Health Choice Medicaid	$316.94
Rate for Payer: Priority Health Cigna Priority Health	$699.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$688.54
Rate for Payer: Priority Health Narrow Network	$688.54
Rate for Payer: Priority Health SBD	$688.54
Rate for Payer: UMR Bronson Commercial	$459.54

PR NASAL/SINUS NDSC TOT W/SPHENDT W/SPHEN TISS RMVL

Professional

Both

$956.00

Service Code	HCPCS 31259
Min. Negotiated Rate	$298.84
Max. Negotiated Rate	$1,218.26
Rate for Payer: Aetna Commercial	$603.57
Rate for Payer: BCBS Complete	$313.78
Rate for Payer: BCBS Trust/PPO	$1,218.26
Rate for Payer: Cash Price	$764.80
Rate for Payer: Cash Price	$764.80
Rate for Payer: Meridian Medicaid	$313.78
Rate for Payer: Priority Health Choice Medicaid	$298.84
Rate for Payer: Priority Health Cigna Priority Health	$669.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$649.19
Rate for Payer: Priority Health Narrow Network	$649.19
Rate for Payer: Priority Health SBD	$649.19
Rate for Payer: UMR Bronson Commercial	$439.76

PR NASAL/SINUS NDSC W/LIG SPHENOPALATINE ARTERY

Professional

Both

$906.00

Service Code	HCPCS 31241
Min. Negotiated Rate	$282.65
Max. Negotiated Rate	$1,456.52
Rate for Payer: Aetna Commercial	$567.94
Rate for Payer: BCBS Complete	$296.78
Rate for Payer: BCBS Trust/PPO	$1,456.52
Rate for Payer: Cash Price	$724.80
Rate for Payer: Cash Price	$724.80
Rate for Payer: Meridian Medicaid	$296.78
Rate for Payer: Priority Health Choice Medicaid	$282.65
Rate for Payer: Priority Health Cigna Priority Health	$634.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$611.68
Rate for Payer: Priority Health Narrow Network	$611.68
Rate for Payer: Priority Health SBD	$611.68
Rate for Payer: UMR Bronson Commercial	$416.76

Know your out-of-pocket cost for care.

All Charges