Bronson Methodist Hospital

All Charges

Charge

Type

Setting

Price

PR PERC VERTEB AUGMENT/ KYPHOPLAST, EA ADD

Professional

Both

$495.00

Service Code	HCPCS 22525
Min. Negotiated Rate	$198.00
Max. Negotiated Rate	$346.50
Rate for Payer: BCBS Complete	$198.00
Rate for Payer: Cash Price	$396.00
Rate for Payer: Priority Health Cigna Priority Health	$346.50
Rate for Payer: UMR Bronson Commercial	$227.70

PR PERC VERTEB AUGMENT/ KYPHOPLAST, LUMBAR

Professional

Both

$1,054.00

Service Code	HCPCS 22524
Min. Negotiated Rate	$421.60
Max. Negotiated Rate	$737.80
Rate for Payer: BCBS Complete	$421.60
Rate for Payer: Cash Price	$843.20
Rate for Payer: Priority Health Cigna Priority Health	$737.80
Rate for Payer: UMR Bronson Commercial	$484.84

PR PERC VERTEB AUGMENT/ KYPHOPLAST, THOR

Professional

Both

$1,119.00

Service Code	HCPCS 22523
Min. Negotiated Rate	$447.60
Max. Negotiated Rate	$783.30
Rate for Payer: BCBS Complete	$447.60
Rate for Payer: Cash Price	$895.20
Rate for Payer: Priority Health Cigna Priority Health	$783.30
Rate for Payer: UMR Bronson Commercial	$514.74

PR PEREYRA PX W/ANTERIOR COLPORRHAPHY

Professional

Both

$2,170.00

Service Code	HCPCS 57289
Min. Negotiated Rate	$510.56
Max. Negotiated Rate	$2,673.73
Rate for Payer: Aetna Commercial	$944.93
Rate for Payer: BCBS Complete	$536.09
Rate for Payer: BCBS Trust/PPO	$2,673.73
Rate for Payer: Cash Price	$1,736.00
Rate for Payer: Cash Price	$1,736.00
Rate for Payer: Meridian Medicaid	$536.09
Rate for Payer: Priority Health Choice Medicaid	$510.56
Rate for Payer: Priority Health Cigna Priority Health	$1,519.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,129.59
Rate for Payer: Priority Health Narrow Network	$1,129.59
Rate for Payer: Priority Health SBD	$1,129.59
Rate for Payer: UMR Bronson Commercial	$998.20

PR PERICARDIOCENTESIS INITIAL

Professional

Both

$442.00

Service Code	HCPCS 33010
Min. Negotiated Rate	$176.80
Max. Negotiated Rate	$309.40
Rate for Payer: BCBS Complete	$176.80
Rate for Payer: Cash Price	$353.60
Rate for Payer: Priority Health Cigna Priority Health	$309.40
Rate for Payer: UMR Bronson Commercial	$203.32

PR PERICARDIOCENTESIS SUBSEQUENT

Professional

Both

$441.00

Service Code	HCPCS 33011
Min. Negotiated Rate	$176.40
Max. Negotiated Rate	$308.70
Rate for Payer: BCBS Complete	$176.40
Rate for Payer: Cash Price	$352.80
Rate for Payer: Priority Health Cigna Priority Health	$308.70
Rate for Payer: UMR Bronson Commercial	$202.86

PR PERICARDIOCENTESIS W/IMG GUIDANCE WHEN PERFORMED

Professional

Both

$485.00

Service Code	HCPCS 33016
Min. Negotiated Rate	$146.33
Max. Negotiated Rate	$1,116.83
Rate for Payer: Aetna Commercial	$317.13
Rate for Payer: BCBS Complete	$153.65
Rate for Payer: BCBS Trust/PPO	$1,116.83
Rate for Payer: Cash Price	$388.00
Rate for Payer: Cash Price	$388.00
Rate for Payer: Meridian Medicaid	$153.65
Rate for Payer: Priority Health Choice Medicaid	$146.33
Rate for Payer: Priority Health Cigna Priority Health	$339.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$364.93
Rate for Payer: Priority Health Narrow Network	$364.93
Rate for Payer: Priority Health SBD	$364.93
Rate for Payer: UMR Bronson Commercial	$223.10

PR PERICARDIOTOMY REMOVAL CLOT/FOREIGN BODY PRIMARY

Professional

Both

$2,605.00

Service Code	HCPCS 33020
Min. Negotiated Rate	$519.08
Max. Negotiated Rate	$1,823.50
Rate for Payer: Aetna Commercial	$1,108.60
Rate for Payer: BCBS Complete	$545.03
Rate for Payer: BCBS Trust/PPO	$745.96
Rate for Payer: Cash Price	$2,084.00
Rate for Payer: Cash Price	$2,084.00
Rate for Payer: Meridian Medicaid	$545.03
Rate for Payer: Priority Health Choice Medicaid	$519.08
Rate for Payer: Priority Health Cigna Priority Health	$1,823.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,293.73
Rate for Payer: Priority Health Narrow Network	$1,293.73
Rate for Payer: Priority Health SBD	$1,293.73
Rate for Payer: UMR Bronson Commercial	$1,198.30

PR PERI-IMPLANT CAPSULECTOMY BREAST COMPLETE

Professional

Both

$2,110.00

Service Code	HCPCS 19371
Min. Negotiated Rate	$456.46
Max. Negotiated Rate	$6,614.63
Rate for Payer: Aetna Commercial	$770.26
Rate for Payer: BCBS Complete	$479.28
Rate for Payer: BCBS Trust/PPO	$6,614.63
Rate for Payer: Cash Price	$1,688.00
Rate for Payer: Cash Price	$1,688.00
Rate for Payer: Meridian Medicaid	$479.28
Rate for Payer: Priority Health Choice Medicaid	$456.46
Rate for Payer: Priority Health Cigna Priority Health	$1,477.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$877.98
Rate for Payer: Priority Health Narrow Network	$877.98
Rate for Payer: Priority Health SBD	$877.98
Rate for Payer: UMR Bronson Commercial	$970.60

PR PERINEOPLASTY RPR PERINEUM NONOBSTETRICAL SPX

Professional

Both

$898.00

Service Code	HCPCS 56810
Min. Negotiated Rate	$175.94
Max. Negotiated Rate	$1,892.90
Rate for Payer: Aetna Commercial	$320.71
Rate for Payer: BCBS Complete	$184.74
Rate for Payer: BCBS Trust/PPO	$1,892.90
Rate for Payer: Cash Price	$718.40
Rate for Payer: Cash Price	$718.40
Rate for Payer: Meridian Medicaid	$184.74
Rate for Payer: Priority Health Choice Medicaid	$175.94
Rate for Payer: Priority Health Cigna Priority Health	$628.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$386.79
Rate for Payer: Priority Health Narrow Network	$386.79
Rate for Payer: Priority Health SBD	$386.79
Rate for Payer: UMR Bronson Commercial	$413.08

PR PERIODIC PREVENTIVE MED ESTABLISHED PATIENT <1Y

Professional

Both

$151.00

Service Code	HCPCS 99391
Min. Negotiated Rate	$61.21
Max. Negotiated Rate	$193.36
Rate for Payer: Aetna Commercial	$71.14
Rate for Payer: BCBS Complete	$64.27
Rate for Payer: BCBS Trust/PPO	$193.36
Rate for Payer: Cash Price	$120.80
Rate for Payer: Cash Price	$120.80
Rate for Payer: Meridian Medicaid	$64.27
Rate for Payer: Priority Health Choice Medicaid	$61.21
Rate for Payer: Priority Health Cigna Priority Health	$105.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$139.81
Rate for Payer: Priority Health Narrow Network	$139.81
Rate for Payer: Priority Health SBD	$139.81
Rate for Payer: UMR Bronson Commercial	$69.46

PR PERIODIC PREVENTIVE MED EST PATIENT 12-17YRS

Professional

Both

$163.00

Service Code	HCPCS 99394
Min. Negotiated Rate	$74.98
Max. Negotiated Rate	$550.49
Rate for Payer: Aetna Commercial	$88.48
Rate for Payer: BCBS Complete	$79.30
Rate for Payer: BCBS Trust/PPO	$550.49
Rate for Payer: Cash Price	$130.40
Rate for Payer: Cash Price	$130.40
Rate for Payer: Meridian Medicaid	$79.30
Rate for Payer: Priority Health Choice Medicaid	$75.52
Rate for Payer: Priority Health Cigna Priority Health	$114.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$107.46
Rate for Payer: Priority Health Narrow Network	$107.46
Rate for Payer: Priority Health SBD	$107.46
Rate for Payer: UMR Bronson Commercial	$74.98

PR PERIODIC PREVENTIVE MED EST PATIENT 1-4YRS

Professional

Both

$162.00

Service Code	HCPCS 99392
Min. Negotiated Rate	$66.69
Max. Negotiated Rate	$527.24
Rate for Payer: Aetna Commercial	$78.23
Rate for Payer: BCBS Complete	$70.02
Rate for Payer: BCBS Trust/PPO	$527.24
Rate for Payer: Cash Price	$129.60
Rate for Payer: Cash Price	$129.60
Rate for Payer: Meridian Medicaid	$70.02
Rate for Payer: Priority Health Choice Medicaid	$66.69
Rate for Payer: Priority Health Cigna Priority Health	$113.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$149.23
Rate for Payer: Priority Health Narrow Network	$149.23
Rate for Payer: Priority Health SBD	$149.23
Rate for Payer: UMR Bronson Commercial	$74.52

PR PERIODIC PREVENTIVE MED EST PATIENT 18-39 YRS

Professional

Both

$166.00

Service Code	HCPCS 99395
Min. Negotiated Rate	$76.36
Max. Negotiated Rate	$668.30
Rate for Payer: Aetna Commercial	$90.96
Rate for Payer: BCBS Complete	$81.54
Rate for Payer: BCBS Trust/PPO	$668.30
Rate for Payer: Cash Price	$132.80
Rate for Payer: Cash Price	$132.80
Rate for Payer: Meridian Medicaid	$81.54
Rate for Payer: Priority Health Choice Medicaid	$77.66
Rate for Payer: Priority Health Cigna Priority Health	$116.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$110.95
Rate for Payer: Priority Health Narrow Network	$110.95
Rate for Payer: Priority Health SBD	$110.95
Rate for Payer: UMR Bronson Commercial	$76.36

PR PERIODIC PREVENTIVE MED EST PATIENT 40-64YRS

Professional

Both

$178.00

Service Code	HCPCS 99396
Min. Negotiated Rate	$81.88
Max. Negotiated Rate	$972.60
Rate for Payer: Aetna Commercial	$98.74
Rate for Payer: BCBS Complete	$89.53
Rate for Payer: BCBS Trust/PPO	$972.60
Rate for Payer: Cash Price	$142.40
Rate for Payer: Cash Price	$142.40
Rate for Payer: Meridian Medicaid	$89.53
Rate for Payer: Priority Health Choice Medicaid	$85.27
Rate for Payer: Priority Health Cigna Priority Health	$124.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$120.13
Rate for Payer: Priority Health Narrow Network	$120.13
Rate for Payer: Priority Health SBD	$120.13
Rate for Payer: UMR Bronson Commercial	$81.88

PR PERIODIC PREVENTIVE MED EST PATIENT 5-11YRS

Professional

Both

$149.00

Service Code	HCPCS 99393
Min. Negotiated Rate	$66.69
Max. Negotiated Rate	$624.98
Rate for Payer: Aetna Commercial	$78.23
Rate for Payer: BCBS Complete	$70.02
Rate for Payer: BCBS Trust/PPO	$624.98
Rate for Payer: Cash Price	$119.20
Rate for Payer: Cash Price	$119.20
Rate for Payer: Meridian Medicaid	$70.02
Rate for Payer: Priority Health Choice Medicaid	$66.69
Rate for Payer: Priority Health Cigna Priority Health	$104.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$95.22
Rate for Payer: Priority Health Narrow Network	$95.22
Rate for Payer: Priority Health SBD	$95.22
Rate for Payer: UMR Bronson Commercial	$68.54

PR PERIODIC PREVENTIVE MED EST PATIENT 65YRS& OLDER

Professional

Both

$192.00

Service Code	HCPCS 99397
Min. Negotiated Rate	$88.32
Max. Negotiated Rate	$977.36
Rate for Payer: Aetna Commercial	$103.72
Rate for Payer: BCBS Complete	$94.33
Rate for Payer: BCBS Trust/PPO	$977.36
Rate for Payer: Cash Price	$153.60
Rate for Payer: Cash Price	$153.60
Rate for Payer: Meridian Medicaid	$94.33
Rate for Payer: Priority Health Choice Medicaid	$89.84
Rate for Payer: Priority Health Cigna Priority Health	$134.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$126.24
Rate for Payer: Priority Health Narrow Network	$126.24
Rate for Payer: Priority Health SBD	$126.24
Rate for Payer: UMR Bronson Commercial	$88.32

PR PERI-PX DEV EVAL PM/LDLS PM PHYS/QHP IN PERSON

Professional

Both

$67.00

Service Code	HCPCS 93286
Min. Negotiated Rate	$20.33
Max. Negotiated Rate	$1,612.37
Rate for Payer: Aetna Commercial	$57.97
Rate for Payer: BCBS Complete	$26.80
Rate for Payer: BCBS Trust/PPO	$1,612.37
Rate for Payer: Cash Price	$53.60
Rate for Payer: Cash Price	$53.60
Rate for Payer: Priority Health Cigna Priority Health	$46.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$20.33
Rate for Payer: Priority Health Narrow Network	$20.33
Rate for Payer: Priority Health SBD	$65.25
Rate for Payer: UMR Bronson Commercial	$30.82

PR PERI-PX DEV EVAL & PROG SING/DUAL/MULTI LEAD DFB

Professional

Both

$46.00

Service Code	HCPCS 93287
Min. Negotiated Rate	$18.40
Max. Negotiated Rate	$1,774.03
Rate for Payer: Aetna Commercial	$68.07
Rate for Payer: BCBS Complete	$18.40
Rate for Payer: BCBS Trust/PPO	$1,774.03
Rate for Payer: Cash Price	$36.80
Rate for Payer: Cash Price	$36.80
Rate for Payer: Priority Health Cigna Priority Health	$32.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$30.74
Rate for Payer: Priority Health Narrow Network	$30.74
Rate for Payer: Priority Health SBD	$75.66
Rate for Payer: UMR Bronson Commercial	$21.16

PR PERIRECTAL INJ SCLEROSING SOLUTION PROLAPSE

Professional

Both

$284.00

Service Code	HCPCS 45520
Min. Negotiated Rate	$25.99
Max. Negotiated Rate	$2,174.48
Rate for Payer: Aetna Commercial	$51.85
Rate for Payer: BCBS Complete	$27.29
Rate for Payer: BCBS Trust/PPO	$2,174.48
Rate for Payer: Cash Price	$227.20
Rate for Payer: Cash Price	$227.20
Rate for Payer: Meridian Medicaid	$27.29
Rate for Payer: Priority Health Choice Medicaid	$25.99
Rate for Payer: Priority Health Cigna Priority Health	$198.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$70.55
Rate for Payer: Priority Health Narrow Network	$70.55
Rate for Payer: Priority Health SBD	$70.55
Rate for Payer: UMR Bronson Commercial	$130.64

PR PERITONEAL LAVAGE W/WO IMAGING GUIDANCE

Professional

Both

$134.00

Service Code	HCPCS 49084
Min. Negotiated Rate	$61.64
Max. Negotiated Rate	$530.41
Rate for Payer: Aetna Commercial	$145.77
Rate for Payer: BCBS Complete	$70.90
Rate for Payer: BCBS Trust/PPO	$530.41
Rate for Payer: Cash Price	$107.20
Rate for Payer: Cash Price	$107.20
Rate for Payer: Meridian Medicaid	$70.90
Rate for Payer: Priority Health Choice Medicaid	$67.52
Rate for Payer: Priority Health Cigna Priority Health	$93.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$186.97
Rate for Payer: Priority Health Narrow Network	$186.97
Rate for Payer: Priority Health SBD	$186.97
Rate for Payer: UMR Bronson Commercial	$61.64

PR PERQ ACCESS & CLOSURE FEM ART FOR DELIVERY NDGFT

Professional

Both

$262.00

Service Code	HCPCS 34713
Min. Negotiated Rate	$76.47
Max. Negotiated Rate	$1,464.98
Rate for Payer: Aetna Commercial	$167.72
Rate for Payer: BCBS Complete	$80.29
Rate for Payer: BCBS Trust/PPO	$1,464.98
Rate for Payer: Cash Price	$209.60
Rate for Payer: Cash Price	$209.60
Rate for Payer: Meridian Medicaid	$80.29
Rate for Payer: Priority Health Choice Medicaid	$76.47
Rate for Payer: Priority Health Cigna Priority Health	$183.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$190.98
Rate for Payer: Priority Health Narrow Network	$190.98
Rate for Payer: Priority Health SBD	$190.98
Rate for Payer: UMR Bronson Commercial	$120.52

PR PERQ ART TRLUML M-THROMBEC &/NFS INTRACRANIAL

Professional

Both

$1,583.00

Service Code	HCPCS 61645
Min. Negotiated Rate	$117.81
Max. Negotiated Rate	$1,416.13
Rate for Payer: Aetna Commercial	$1,083.12
Rate for Payer: BCBS Complete	$562.93
Rate for Payer: BCBS Trust/PPO	$117.81
Rate for Payer: Cash Price	$1,266.40
Rate for Payer: Cash Price	$1,266.40
Rate for Payer: Meridian Medicaid	$562.93
Rate for Payer: Priority Health Choice Medicaid	$536.12
Rate for Payer: Priority Health Cigna Priority Health	$1,108.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,416.13
Rate for Payer: Priority Health Narrow Network	$1,416.13
Rate for Payer: Priority Health SBD	$1,416.13
Rate for Payer: UMR Bronson Commercial	$728.18

PR PERQ BALO DILA IC VSPSM EA VSL DIFF VASC TER

Professional

Both

$679.00

Service Code	HCPCS 61642
Min. Negotiated Rate	$109.36
Max. Negotiated Rate	$557.16
Rate for Payer: Aetna Commercial	$445.23
Rate for Payer: BCBS Complete	$271.60
Rate for Payer: BCBS Trust/PPO	$109.36
Rate for Payer: Cash Price	$543.20
Rate for Payer: Cash Price	$543.20
Rate for Payer: Priority Health Cigna Priority Health	$475.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$557.16
Rate for Payer: Priority Health Narrow Network	$557.16
Rate for Payer: Priority Health SBD	$557.16
Rate for Payer: UMR Bronson Commercial	$312.34

PR PERQ BALO DILA IC VSPSM EA VSL SM VASC TER

Professional

Both

$340.00

Service Code	HCPCS 61641
Min. Negotiated Rate	$105.66
Max. Negotiated Rate	$278.59
Rate for Payer: Aetna Commercial	$222.61
Rate for Payer: BCBS Complete	$136.00
Rate for Payer: BCBS Trust/PPO	$105.66
Rate for Payer: Cash Price	$272.00
Rate for Payer: Cash Price	$272.00
Rate for Payer: Priority Health Cigna Priority Health	$238.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$278.59
Rate for Payer: Priority Health Narrow Network	$278.59
Rate for Payer: Priority Health SBD	$278.59
Rate for Payer: UMR Bronson Commercial	$156.40

Know your out-of-pocket cost for care.

All Charges