Bronson Methodist Hospital

All Charges

Charge

Type

Setting

Price

PR PATIENT-INITIATED SPIROMETRIC RECORDING

Professional

Both

$50.00

Service Code	HCPCS 94015
Min. Negotiated Rate	$20.00
Max. Negotiated Rate	$1,168.60
Rate for Payer: Aetna Commercial	$32.07
Rate for Payer: BCBS Complete	$20.00
Rate for Payer: BCBS Trust/PPO	$1,168.60
Rate for Payer: Cash Price	$40.00
Rate for Payer: Cash Price	$40.00
Rate for Payer: Priority Health Cigna Priority Health	$35.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$41.33
Rate for Payer: Priority Health Narrow Network	$41.33
Rate for Payer: Priority Health SBD	$41.33
Rate for Payer: UMR Bronson Commercial	$23.00

PR PCV13 VACCINE FOR INTRAMUSCULAR USE

Professional

Both

$284.00

Service Code	HCPCS 90670
Min. Negotiated Rate	$113.60
Max. Negotiated Rate	$270.00
Rate for Payer: Aetna Commercial	$257.99
Rate for Payer: BCBS Complete	$113.60
Rate for Payer: BCBS Trust/PPO	$270.00
Rate for Payer: Cash Price	$227.20
Rate for Payer: Cash Price	$227.20
Rate for Payer: Priority Health Cigna Priority Health	$198.80
Rate for Payer: UMR Bronson Commercial	$130.64

PR PCV20 VACCINE FOR INTRAMUSCULAR USE

Professional

Both

$290.00

Service Code	HCPCS 90677
Min. Negotiated Rate	$116.00
Max. Negotiated Rate	$298.65
Rate for Payer: Aetna Commercial	$288.66
Rate for Payer: BCBS Complete	$116.00
Rate for Payer: BCBS Trust/PPO	$298.65
Rate for Payer: Cash Price	$232.00
Rate for Payer: Cash Price	$232.00
Rate for Payer: Priority Health Cigna Priority Health	$203.00
Rate for Payer: UMR Bronson Commercial	$133.40

PR PDT DSTR PRMLG LES SKN ILLUM/ACTIVJ BY PHYS/QHP

Professional

Both

$358.00

Service Code	HCPCS 96573
Min. Negotiated Rate	$143.20
Max. Negotiated Rate	$1,125.28
Rate for Payer: Aetna Commercial	$247.38
Rate for Payer: BCBS Complete	$143.20
Rate for Payer: BCBS Trust/PPO	$1,125.28
Rate for Payer: Cash Price	$286.40
Rate for Payer: Cash Price	$286.40
Rate for Payer: Priority Health Cigna Priority Health	$250.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$309.91
Rate for Payer: Priority Health Narrow Network	$309.91
Rate for Payer: Priority Health SBD	$309.91
Rate for Payer: UMR Bronson Commercial	$164.68

PR PDT DSTR PRMLG LES SKN ILLUM/ACTIVJ PER DAY

Professional

Both

$214.00

Service Code	HCPCS 96567
Min. Negotiated Rate	$85.60
Max. Negotiated Rate	$2,195.61
Rate for Payer: Aetna Commercial	$151.34
Rate for Payer: BCBS Complete	$85.60
Rate for Payer: BCBS Trust/PPO	$2,195.61
Rate for Payer: Cash Price	$171.20
Rate for Payer: Cash Price	$171.20
Rate for Payer: Priority Health Cigna Priority Health	$149.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$189.10
Rate for Payer: Priority Health Narrow Network	$189.10
Rate for Payer: Priority Health SBD	$189.10
Rate for Payer: UMR Bronson Commercial	$98.44

PR PEL LMPHADEC W/XTRNL ILIAC HYPOGSTR&OBTURATOR

Professional

Both

$1,273.00

Service Code	HCPCS 38770
Min. Negotiated Rate	$391.47
Max. Negotiated Rate	$1,729.73
Rate for Payer: Aetna Commercial	$995.43
Rate for Payer: BCBS Complete	$540.78
Rate for Payer: BCBS Trust/PPO	$391.47
Rate for Payer: Cash Price	$1,018.40
Rate for Payer: Cash Price	$1,018.40
Rate for Payer: Meridian Medicaid	$540.78
Rate for Payer: Priority Health Choice Medicaid	$515.03
Rate for Payer: Priority Health Cigna Priority Health	$891.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,729.73
Rate for Payer: Priority Health Narrow Network	$1,729.73
Rate for Payer: Priority Health SBD	$1,729.73
Rate for Payer: UMR Bronson Commercial	$585.58

PR PELVIC EXAMINATION W/ANESTHESIA OTHER THAN LOCAL

Professional

Both

$192.00

Service Code	HCPCS 57410
Min. Negotiated Rate	$67.95
Max. Negotiated Rate	$1,808.90
Rate for Payer: Aetna Commercial	$125.13
Rate for Payer: BCBS Complete	$71.35
Rate for Payer: BCBS Trust/PPO	$1,808.90
Rate for Payer: Cash Price	$153.60
Rate for Payer: Cash Price	$153.60
Rate for Payer: Meridian Medicaid	$71.35
Rate for Payer: Priority Health Choice Medicaid	$67.95
Rate for Payer: Priority Health Cigna Priority Health	$134.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$148.66
Rate for Payer: Priority Health Narrow Network	$148.66
Rate for Payer: Priority Health SBD	$148.66
Rate for Payer: UMR Bronson Commercial	$88.32

PR PELVIC EXAMINATION W/ANESTHESIA OTHER THAN LOCAL

Facility

$192.00

Service Code	CPT 57410
Hospital Charge Code	57410
Min. Negotiated Rate	$84.48
Max. Negotiated Rate	$172.80
Rate for Payer: Aetna American Axle	$124.80
Rate for Payer: Aetna Commercial	$163.20
Rate for Payer: Aetna New Business (MI Preferred)	$124.80
Rate for Payer: Cash Price	$153.60
Rate for Payer: Cofinity Commercial	$134.40
Rate for Payer: Cofinity Commercial	$165.12
Rate for Payer: Encore Health Key Benefits Commercial	$153.60
Rate for Payer: Healthscope Commercial	$172.80
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial	$134.40
Rate for Payer: Lakeland Regional Health Systems Commercial	$144.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$163.20
Rate for Payer: PHP Commercial	$163.20
Rate for Payer: Priority Health Cigna Priority Health	$134.40
Rate for Payer: Priority Health SBD	$120.96
Rate for Payer: UMR Bronson Commercial	$84.48
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$144.00

PR PELVIC EXAMINATION W/ANESTHESIA OTHER THAN LOCAL

Facility

$192.00

Service Code	CPT 57410
Hospital Charge Code	57410
Min. Negotiated Rate	$71.04
Max. Negotiated Rate	$8,748.29
Rate for Payer: Aetna American Axle	$124.80
Rate for Payer: Aetna Commercial	$163.20
Rate for Payer: Aetna Medicare	$2,890.11
Rate for Payer: Aetna New Business (MI Preferred)	$124.80
Rate for Payer: Allen County Amish Medical Aid Commercial	$3,473.69
Rate for Payer: Amish Plain Church Group Commercial	$3,473.69
Rate for Payer: BCBS Complete	$1,596.23
Rate for Payer: BCBS MAPPO	$2,778.95
Rate for Payer: BCBS Trust/PPO	$2,692.96
Rate for Payer: BCN Medicare Advantage	$2,778.95
Rate for Payer: Cash Price	$153.60
Rate for Payer: Cash Price	$153.60
Rate for Payer: Cofinity Commercial	$165.12
Rate for Payer: Cofinity Commercial	$134.40
Rate for Payer: Encore Health Key Benefits Commercial	$153.60
Rate for Payer: Health Alliance Plan Medicare Advantage	$2,778.95
Rate for Payer: Healthscope Commercial	$172.80
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial	$134.40
Rate for Payer: Lakeland Regional Health Systems Commercial	$144.00
Rate for Payer: Mclaren Medicaid	$1,520.09
Rate for Payer: Mclaren Medicare	$2,778.95
Rate for Payer: Meridian Medicaid	$1,596.23
Rate for Payer: Meridian Wellcare - Medicare Advantage	$2,917.90
Rate for Payer: MI Amish Medical Board Commercial	$3,195.79
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$163.20
Rate for Payer: PACE Medicare	$2,640.00
Rate for Payer: PACE SWMI	$2,778.95
Rate for Payer: PHP Commercial	$163.20
Rate for Payer: PHP Medicare Advantage	$2,778.95
Rate for Payer: Priority Health Choice Medicaid	$1,520.09
Rate for Payer: Priority Health Cigna Priority Health	$134.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$8,748.29
Rate for Payer: Priority Health Medicare	$2,778.95
Rate for Payer: Priority Health Narrow Network	$6,998.63
Rate for Payer: Priority Health SBD	$120.96
Rate for Payer: Railroad Medicare Medicare	$2,778.95
Rate for Payer: UHC All Payor (Choice/PPO)	$114.90
Rate for Payer: UHC Dual Complete DSNP	$2,778.95
Rate for Payer: UHC Exchange	$104.45
Rate for Payer: UHC Medicare Advantage	$2,862.32
Rate for Payer: UMR Bronson Commercial	$71.04
Rate for Payer: VA VA	$2,778.95
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$144.00

PR PELVIC EXAMINATION W/ANESTHESIA OTHER THAN LOCAL

Professional

Both

$192.00

Service Code	HCPCS 57410
Hospital Charge Code	57410
Min. Negotiated Rate	$67.95
Max. Negotiated Rate	$1,808.90
Rate for Payer: Aetna Commercial	$125.13
Rate for Payer: BCBS Complete	$71.35
Rate for Payer: BCBS Trust/PPO	$1,808.90
Rate for Payer: Cash Price	$153.60
Rate for Payer: Cash Price	$153.60
Rate for Payer: Meridian Medicaid	$71.35
Rate for Payer: Priority Health Choice Medicaid	$67.95
Rate for Payer: Priority Health Cigna Priority Health	$134.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$148.66
Rate for Payer: Priority Health Narrow Network	$148.66
Rate for Payer: Priority Health SBD	$148.66
Rate for Payer: UMR Bronson Commercial	$88.32

PR PELVIC FIXATION OTHER THAN SACRUM

Professional

Both

$1,756.00

Service Code	HCPCS 22848
Min. Negotiated Rate	$65.80
Max. Negotiated Rate	$1,229.20
Rate for Payer: Aetna Commercial	$484.23
Rate for Payer: BCBS Complete	$240.20
Rate for Payer: BCBS Trust/PPO	$65.80
Rate for Payer: Cash Price	$1,404.80
Rate for Payer: Cash Price	$1,404.80
Rate for Payer: Meridian Medicaid	$240.20
Rate for Payer: Priority Health Choice Medicaid	$228.76
Rate for Payer: Priority Health Cigna Priority Health	$1,229.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$545.88
Rate for Payer: Priority Health Narrow Network	$545.88
Rate for Payer: Priority Health SBD	$545.88
Rate for Payer: UMR Bronson Commercial	$807.76

PR PELVIC RING FRACTURE UNI/BIL

Professional

Both

$3,110.00

Service Code	HCPCS G0413
Min. Negotiated Rate	$238.26
Max. Negotiated Rate	$2,177.00
Rate for Payer: Aetna Commercial	$1,062.63
Rate for Payer: BCBS Complete	$718.37
Rate for Payer: BCBS Trust/PPO	$238.26
Rate for Payer: Cash Price	$2,488.00
Rate for Payer: Cash Price	$2,488.00
Rate for Payer: Meridian Medicaid	$718.37
Rate for Payer: Priority Health Choice Medicaid	$684.16
Rate for Payer: Priority Health Cigna Priority Health	$2,177.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,627.95
Rate for Payer: Priority Health Narrow Network	$1,627.95
Rate for Payer: Priority Health SBD	$1,627.95
Rate for Payer: UMR Bronson Commercial	$1,430.60

PR PELVIC RING FX TREAT INT FIX

Professional

Both

$3,073.00

Service Code	HCPCS G0414
Min. Negotiated Rate	$364.00
Max. Negotiated Rate	$2,151.10
Rate for Payer: Aetna Commercial	$1,004.21
Rate for Payer: BCBS Complete	$677.88
Rate for Payer: BCBS Trust/PPO	$364.00
Rate for Payer: Cash Price	$2,458.40
Rate for Payer: Cash Price	$2,458.40
Rate for Payer: Meridian Medicaid	$677.88
Rate for Payer: Priority Health Choice Medicaid	$645.60
Rate for Payer: Priority Health Cigna Priority Health	$2,151.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,535.53
Rate for Payer: Priority Health Narrow Network	$1,535.53
Rate for Payer: Priority Health SBD	$1,535.53
Rate for Payer: UMR Bronson Commercial	$1,413.58

PR PENG BENZATHINE/PROCAINE INJ

Professional

Both

$6.00

Service Code	HCPCS J0558
Min. Negotiated Rate	$2.40
Max. Negotiated Rate	$18.11
Rate for Payer: Aetna Commercial	$18.11
Rate for Payer: BCBS Complete	$2.40
Rate for Payer: BCBS Trust/PPO	$17.90
Rate for Payer: Cash Price	$4.80
Rate for Payer: Cash Price	$4.80
Rate for Payer: Priority Health Cigna Priority Health	$4.20
Rate for Payer: UMR Bronson Commercial	$2.76

PR PENICILLIN G BENZATHINE INJ

Professional

Both

$10.00

Service Code	HCPCS J0561
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$22.38
Rate for Payer: Aetna Commercial	$22.38
Rate for Payer: BCBS Complete	$4.00
Rate for Payer: BCBS Trust/PPO	$21.19
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 PENILE PLETHYSMOGRAPHY

Professional

Both

$184.00

Service Code	HCPCS 54240
Min. Negotiated Rate	$67.55
Max. Negotiated Rate	$680.45
Rate for Payer: Aetna Commercial	$131.41
Rate for Payer: BCBS Complete	$73.60
Rate for Payer: BCBS Trust/PPO	$680.45
Rate for Payer: Cash Price	$147.20
Rate for Payer: Cash Price	$147.20
Rate for Payer: Priority Health Cigna Priority Health	$128.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$67.55
Rate for Payer: Priority Health Narrow Network	$67.55
Rate for Payer: Priority Health SBD	$172.37
Rate for Payer: UMR Bronson Commercial	$84.64

PR PENIS CORRJ CHORDEE/1ST STAGE HYPOSPADIAS RPR

Professional

Both

$5,098.00

Service Code	HCPCS 54304
Min. Negotiated Rate	$316.45
Max. Negotiated Rate	$3,568.60
Rate for Payer: Aetna Commercial	$960.40
Rate for Payer: BCBS Complete	$499.63
Rate for Payer: BCBS Trust/PPO	$316.45
Rate for Payer: Cash Price	$4,078.40
Rate for Payer: Cash Price	$4,078.40
Rate for Payer: Meridian Medicaid	$499.63
Rate for Payer: Priority Health Choice Medicaid	$475.84
Rate for Payer: Priority Health Cigna Priority Health	$3,568.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,192.03
Rate for Payer: Priority Health Narrow Network	$1,192.03
Rate for Payer: Priority Health SBD	$1,192.03
Rate for Payer: UMR Bronson Commercial	$2,345.08

PR PENIS STRAIGHTENING CHORDEE

Professional

Both

$1,309.68

Service Code	HCPCS 54300
Min. Negotiated Rate	$311.17
Max. Negotiated Rate	$1,029.92
Rate for Payer: Aetna Commercial	$828.72
Rate for Payer: BCBS Complete	$432.10
Rate for Payer: BCBS Trust/PPO	$311.17
Rate for Payer: Cash Price	$1,047.74
Rate for Payer: Cash Price	$1,047.74
Rate for Payer: Meridian Medicaid	$432.10
Rate for Payer: Priority Health Choice Medicaid	$411.52
Rate for Payer: Priority Health Cigna Priority Health	$916.78
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,029.92
Rate for Payer: Priority Health Narrow Network	$1,029.92
Rate for Payer: Priority Health SBD	$1,029.92
Rate for Payer: UMR Bronson Commercial	$602.45

PR PENTAMIDINE AERSL INHALATION PNEUMOCYSTIS/PROPH

Professional

Both

$186.00

Service Code	HCPCS 94642
Min. Negotiated Rate	$18.04
Max. Negotiated Rate	$217.66
Rate for Payer: Aetna Commercial	$46.35
Rate for Payer: BCBS Complete	$18.94
Rate for Payer: BCBS Trust/PPO	$217.66
Rate for Payer: Cash Price	$148.80
Rate for Payer: Cash Price	$148.80
Rate for Payer: Meridian Medicaid	$18.94
Rate for Payer: Priority Health Choice Medicaid	$18.04
Rate for Payer: Priority Health Cigna Priority Health	$130.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$56.14
Rate for Payer: Priority Health Narrow Network	$56.14
Rate for Payer: Priority Health SBD	$56.14
Rate for Payer: UMR Bronson Commercial	$85.56

PR PERCUTANEOUS TX MALAR AREA FRACTURE

Professional

Both

$898.00

Service Code	HCPCS 21355
Min. Negotiated Rate	$32.75
Max. Negotiated Rate	$628.60
Rate for Payer: Aetna Commercial	$427.46
Rate for Payer: BCBS Complete	$222.98
Rate for Payer: BCBS Trust/PPO	$32.75
Rate for Payer: Cash Price	$718.40
Rate for Payer: Cash Price	$718.40
Rate for Payer: Meridian Medicaid	$222.98
Rate for Payer: Priority Health Choice Medicaid	$212.36
Rate for Payer: Priority Health Cigna Priority Health	$628.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$506.05
Rate for Payer: Priority Health Narrow Network	$506.05
Rate for Payer: Priority Health SBD	$506.05
Rate for Payer: UMR Bronson Commercial	$413.08

PR PERCUTANEOUS VERTEBROPLASTY EA ADDL THRC/LMBR

Professional

Both

$705.00

Service Code	HCPCS 22522
Min. Negotiated Rate	$282.00
Max. Negotiated Rate	$493.50
Rate for Payer: BCBS Complete	$282.00
Rate for Payer: Cash Price	$564.00
Rate for Payer: Priority Health Cigna Priority Health	$493.50
Rate for Payer: UMR Bronson Commercial	$324.30

PR PERCUTANEOUS VERTEBROPLASTY LUMBAR W/WO BNE BX

Professional

Both

$5,631.00

Service Code	HCPCS 22521
Min. Negotiated Rate	$2,252.40
Max. Negotiated Rate	$3,941.70
Rate for Payer: BCBS Complete	$2,252.40
Rate for Payer: Cash Price	$4,504.80
Rate for Payer: Priority Health Cigna Priority Health	$3,941.70
Rate for Payer: UMR Bronson Commercial	$2,590.26

PR PERCUTANEOUS VERTEBROPLSTY THORACIC W/WO BONE BX

Professional

Both

$7,687.00

Service Code	HCPCS 22520
Min. Negotiated Rate	$3,074.80
Max. Negotiated Rate	$5,380.90
Rate for Payer: BCBS Complete	$3,074.80
Rate for Payer: Cash Price	$6,149.60
Rate for Payer: Priority Health Cigna Priority Health	$5,380.90
Rate for Payer: UMR Bronson Commercial	$3,536.02

PR PERCUT DILATN RENAL TRACT

Professional

Both

$340.00

Service Code	HCPCS 50395
Min. Negotiated Rate	$136.00
Max. Negotiated Rate	$238.00
Rate for Payer: BCBS Complete	$136.00
Rate for Payer: Cash Price	$272.00
Rate for Payer: Priority Health Cigna Priority Health	$238.00
Rate for Payer: UMR Bronson Commercial	$156.40

PR PERCUT INSERT KIDNEY CATH/DRAIN

Professional

Both

$358.00

Service Code	HCPCS 50392
Min. Negotiated Rate	$143.20
Max. Negotiated Rate	$250.60
Rate for Payer: BCBS Complete	$143.20
Rate for Payer: Cash Price	$286.40
Rate for Payer: Priority Health Cigna Priority Health	$250.60
Rate for Payer: UMR Bronson Commercial	$164.68

Know your out-of-pocket cost for care.

All Charges