Bronson Methodist Hospital

All Charges

Charge

Type

Setting

Price

PR PERQ BREAST LOC DEVICE PLACEMT 1ST LESIO US IMAG

Professional

Both

$220.00

Service Code	HCPCS 19285
Min. Negotiated Rate	$52.61
Max. Negotiated Rate	$2,904.75
Rate for Payer: Aetna Commercial	$92.57
Rate for Payer: BCBS Complete	$55.24
Rate for Payer: BCBS Trust/PPO	$2,904.75
Rate for Payer: Cash Price	$176.00
Rate for Payer: Cash Price	$176.00
Rate for Payer: Meridian Medicaid	$55.24
Rate for Payer: Priority Health Choice Medicaid	$52.61
Rate for Payer: Priority Health Cigna Priority Health	$154.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$102.76
Rate for Payer: Priority Health Narrow Network	$102.76
Rate for Payer: Priority Health SBD	$102.76
Rate for Payer: UMR Bronson Commercial	$101.20

PR PERQ BREAST LOC DEVICE PLACEMT EACH LES US IMAGE

Professional

Both

$67.00

Service Code	HCPCS 19286
Min. Negotiated Rate	$26.41
Max. Negotiated Rate	$570.00
Rate for Payer: Aetna Commercial	$46.85
Rate for Payer: BCBS Complete	$27.73
Rate for Payer: BCBS Trust/PPO	$570.00
Rate for Payer: Cash Price	$53.60
Rate for Payer: Cash Price	$53.60
Rate for Payer: Meridian Medicaid	$27.73
Rate for Payer: Priority Health Choice Medicaid	$26.41
Rate for Payer: Priority Health Cigna Priority Health	$46.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$51.79
Rate for Payer: Priority Health Narrow Network	$51.79
Rate for Payer: Priority Health SBD	$51.79
Rate for Payer: UMR Bronson Commercial	$30.82

PR PERQ CLSR TCAT L ATR APNDGE W/ENDOCARDIAL IMPLNT

Professional

Both

$1,630.00

Service Code	HCPCS 33340
Min. Negotiated Rate	$486.49
Max. Negotiated Rate	$1,221.37
Rate for Payer: Aetna Commercial	$1,058.20
Rate for Payer: BCBS Complete	$510.81
Rate for Payer: BCBS Trust/PPO	$775.02
Rate for Payer: Cash Price	$1,304.00
Rate for Payer: Cash Price	$1,304.00
Rate for Payer: Meridian Medicaid	$510.81
Rate for Payer: Priority Health Choice Medicaid	$486.49
Rate for Payer: Priority Health Cigna Priority Health	$1,141.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,221.37
Rate for Payer: Priority Health Narrow Network	$1,221.37
Rate for Payer: Priority Health SBD	$1,221.37
Rate for Payer: UMR Bronson Commercial	$749.80

PR PERQ DEVICE PLACEMENT BREAST LOC 1ST LES W/GDNCE

Professional

Both

$359.00

Service Code	HCPCS 19281
Min. Negotiated Rate	$61.56
Max. Negotiated Rate	$251.30
Rate for Payer: Aetna Commercial	$107.95
Rate for Payer: BCBS Complete	$64.64
Rate for Payer: BCBS Trust/PPO	$100.60
Rate for Payer: Cash Price	$287.20
Rate for Payer: Cash Price	$287.20
Rate for Payer: Meridian Medicaid	$64.64
Rate for Payer: Priority Health Choice Medicaid	$61.56
Rate for Payer: Priority Health Cigna Priority Health	$251.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$119.61
Rate for Payer: Priority Health Narrow Network	$119.61
Rate for Payer: Priority Health SBD	$119.61
Rate for Payer: UMR Bronson Commercial	$165.14

PR PERQ DEVICE PLACEMT BREAST LOC EA LESION W/GDNCE

Professional

Both

$250.00

Service Code	HCPCS 19282
Min. Negotiated Rate	$30.89
Max. Negotiated Rate	$2,700.00
Rate for Payer: Aetna Commercial	$54.35
Rate for Payer: BCBS Complete	$32.43
Rate for Payer: BCBS Trust/PPO	$2,700.00
Rate for Payer: Cash Price	$200.00
Rate for Payer: Cash Price	$200.00
Rate for Payer: Meridian Medicaid	$32.43
Rate for Payer: Priority Health Choice Medicaid	$30.89
Rate for Payer: Priority Health Cigna Priority Health	$175.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$60.42
Rate for Payer: Priority Health Narrow Network	$60.42
Rate for Payer: Priority Health SBD	$60.42
Rate for Payer: UMR Bronson Commercial	$115.00

PR PERQ DILATION XST TRC ENDOUROLOGIC PX W/IMG

Professional

Both

$299.00

Service Code	HCPCS 50436
Min. Negotiated Rate	$93.29
Max. Negotiated Rate	$1,729.65
Rate for Payer: Aetna Commercial	$192.23
Rate for Payer: BCBS Complete	$97.95
Rate for Payer: BCBS Trust/PPO	$1,729.65
Rate for Payer: Cash Price	$239.20
Rate for Payer: Cash Price	$239.20
Rate for Payer: Meridian Medicaid	$97.95
Rate for Payer: Priority Health Choice Medicaid	$93.29
Rate for Payer: Priority Health Cigna Priority Health	$209.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$235.60
Rate for Payer: Priority Health Narrow Network	$235.60
Rate for Payer: Priority Health SBD	$235.60
Rate for Payer: UMR Bronson Commercial	$137.54

PR PERQ DRAINAGE PLEURA INSERT CATH W/IMAGING

Professional

Both

$965.00

Service Code	HCPCS 32557
Min. Negotiated Rate	$93.08
Max. Negotiated Rate	$675.50
Rate for Payer: Aetna Commercial	$193.57
Rate for Payer: BCBS Complete	$97.73
Rate for Payer: BCBS Trust/PPO	$656.15
Rate for Payer: Cash Price	$772.00
Rate for Payer: Cash Price	$772.00
Rate for Payer: Meridian Medicaid	$97.73
Rate for Payer: Priority Health Choice Medicaid	$93.08
Rate for Payer: Priority Health Cigna Priority Health	$675.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$202.82
Rate for Payer: Priority Health Narrow Network	$202.82
Rate for Payer: Priority Health SBD	$202.82
Rate for Payer: UMR Bronson Commercial	$443.90

PR PERQ DRAINAGE PLEURA INSERT CATH W/O IMAGING

Professional

Both

$867.00

Service Code	HCPCS 32556
Min. Negotiated Rate	$77.96
Max. Negotiated Rate	$606.90
Rate for Payer: Aetna Commercial	$159.78
Rate for Payer: BCBS Complete	$81.86
Rate for Payer: BCBS Trust/PPO	$507.70
Rate for Payer: Cash Price	$693.60
Rate for Payer: Cash Price	$693.60
Rate for Payer: Meridian Medicaid	$81.86
Rate for Payer: Priority Health Choice Medicaid	$77.96
Rate for Payer: Priority Health Cigna Priority Health	$606.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$169.01
Rate for Payer: Priority Health Narrow Network	$169.01
Rate for Payer: Priority Health SBD	$169.01
Rate for Payer: UMR Bronson Commercial	$398.82

PR PERQ NL/PL LITHOTRP COMPLEX >2 CM MLT LOCATIONS

Professional

Both

$2,400.00

Service Code	HCPCS 50081
Min. Negotiated Rate	$712.27
Max. Negotiated Rate	$2,246.86
Rate for Payer: Aetna Commercial	$1,639.65
Rate for Payer: BCBS Complete	$747.88
Rate for Payer: BCBS Trust/PPO	$2,246.86
Rate for Payer: Cash Price	$1,920.00
Rate for Payer: Cash Price	$1,920.00
Rate for Payer: Meridian Medicaid	$747.88
Rate for Payer: Priority Health Choice Medicaid	$712.27
Rate for Payer: Priority Health Cigna Priority Health	$1,680.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,789.13
Rate for Payer: Priority Health Narrow Network	$1,789.13
Rate for Payer: Priority Health SBD	$1,789.13
Rate for Payer: UMR Bronson Commercial	$1,104.00

PR PERQ NL/PL LITHOTRP SIMPLE UP TO 2 CM 1 LOCATION

Professional

Both

$1,631.00

Service Code	HCPCS 50080
Min. Negotiated Rate	$442.83
Max. Negotiated Rate	$1,141.70
Rate for Payer: Aetna Commercial	$1,115.07
Rate for Payer: BCBS Complete	$464.97
Rate for Payer: BCBS Trust/PPO	$652.45
Rate for Payer: Cash Price	$1,304.80
Rate for Payer: Cash Price	$1,304.80
Rate for Payer: Meridian Medicaid	$464.97
Rate for Payer: Priority Health Choice Medicaid	$442.83
Rate for Payer: Priority Health Cigna Priority Health	$1,141.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,110.43
Rate for Payer: Priority Health Narrow Network	$1,110.43
Rate for Payer: Priority Health SBD	$1,110.43
Rate for Payer: UMR Bronson Commercial	$750.26

PR PERQ PRCRD DRG 6YR+ W/O CONGENITAL CAR ANOMALY

Professional

Both

$498.00

Service Code	HCPCS 33017
Min. Negotiated Rate	$154.43
Max. Negotiated Rate	$750.19
Rate for Payer: Aetna Commercial	$328.72
Rate for Payer: BCBS Complete	$162.15
Rate for Payer: BCBS Trust/PPO	$750.19
Rate for Payer: Cash Price	$398.40
Rate for Payer: Cash Price	$398.40
Rate for Payer: Meridian Medicaid	$162.15
Rate for Payer: Priority Health Choice Medicaid	$154.43
Rate for Payer: Priority Health Cigna Priority Health	$348.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$383.01
Rate for Payer: Priority Health Narrow Network	$383.01
Rate for Payer: Priority Health SBD	$383.01
Rate for Payer: UMR Bronson Commercial	$229.08

PR PERQ REPLACEMENT GTUBE NOT REQ REVJ GSTRST TRC

Professional

Both

$423.00

Service Code	HCPCS 43762
Min. Negotiated Rate	$23.64
Max. Negotiated Rate	$296.10
Rate for Payer: Aetna Commercial	$51.19
Rate for Payer: BCBS Complete	$24.82
Rate for Payer: BCBS Trust/PPO	$210.26
Rate for Payer: Cash Price	$338.40
Rate for Payer: Cash Price	$338.40
Rate for Payer: Meridian Medicaid	$24.82
Rate for Payer: Priority Health Choice Medicaid	$23.64
Rate for Payer: Priority Health Cigna Priority Health	$296.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$64.09
Rate for Payer: Priority Health Narrow Network	$64.09
Rate for Payer: Priority Health SBD	$64.09
Rate for Payer: UMR Bronson Commercial	$194.58

PR PERQ REPLACEMENT GTUBE REQ REVJ GSTRST TRC

Professional

Both

$630.00

Service Code	HCPCS 43763
Min. Negotiated Rate	$55.59
Max. Negotiated Rate	$750.19
Rate for Payer: Aetna Commercial	$112.71
Rate for Payer: BCBS Complete	$58.37
Rate for Payer: BCBS Trust/PPO	$750.19
Rate for Payer: Cash Price	$504.00
Rate for Payer: Cash Price	$504.00
Rate for Payer: Meridian Medicaid	$58.37
Rate for Payer: Priority Health Choice Medicaid	$55.59
Rate for Payer: Priority Health Cigna Priority Health	$441.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$152.29
Rate for Payer: Priority Health Narrow Network	$152.29
Rate for Payer: Priority Health SBD	$152.29
Rate for Payer: UMR Bronson Commercial	$289.80

PR PERQ SAC AGMNTJ BI W/WO BALO/MCHNL DEV 2/> NDLS

Professional

Both

$2,396.00

Service Code	HCPCS 0201T
Min. Negotiated Rate	$237.73
Max. Negotiated Rate	$3,600.00
Rate for Payer: Aetna Commercial	$2,396.07
Rate for Payer: BCBS Complete	$249.62
Rate for Payer: BCBS Trust/PPO	$3,600.00
Rate for Payer: Cash Price	$1,916.80
Rate for Payer: Cash Price	$1,916.80
Rate for Payer: Meridian Medicaid	$249.62
Rate for Payer: Priority Health Choice Medicaid	$237.73
Rate for Payer: Priority Health Cigna Priority Health	$1,677.20
Rate for Payer: UMR Bronson Commercial	$1,102.16

PR PERQ SAC AGMNTJ UNI W/WO BALO/MCHNL DEV 1/> NDL

Professional

Both

$2,272.00

Service Code	HCPCS 0200T
Min. Negotiated Rate	$64.33
Max. Negotiated Rate	$2,325.11
Rate for Payer: Aetna Commercial	$2,325.11
Rate for Payer: BCBS Complete	$249.62
Rate for Payer: BCBS Trust/PPO	$64.33
Rate for Payer: Cash Price	$1,817.60
Rate for Payer: Cash Price	$1,817.60
Rate for Payer: Meridian Medicaid	$249.62
Rate for Payer: Priority Health Choice Medicaid	$237.73
Rate for Payer: Priority Health Cigna Priority Health	$1,590.40
Rate for Payer: UMR Bronson Commercial	$1,045.12

PR PERQ SKELETAL FIXATION PST PELVIC BONE FX&/DIS

Professional

Both

$3,110.00

Service Code	HCPCS 27216
Min. Negotiated Rate	$571.69
Max. Negotiated Rate	$2,177.00
Rate for Payer: Aetna Commercial	$1,191.27
Rate for Payer: BCBS Complete	$600.27
Rate for Payer: BCBS Trust/PPO	$1,616.07
Rate for Payer: Cash Price	$2,488.00
Rate for Payer: Cash Price	$2,488.00
Rate for Payer: Meridian Medicaid	$600.27
Rate for Payer: Priority Health Choice Medicaid	$571.69
Rate for Payer: Priority Health Cigna Priority Health	$2,177.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,360.88
Rate for Payer: Priority Health Narrow Network	$1,360.88
Rate for Payer: Priority Health SBD	$1,360.88
Rate for Payer: UMR Bronson Commercial	$1,430.60

PR PERQ SKEL FIXJ DISTAL RADIAL FX/EPIPHYSL SEP

Professional

Both

$1,906.00

Service Code	HCPCS 25606
Min. Negotiated Rate	$72.38
Max. Negotiated Rate	$1,334.20
Rate for Payer: Aetna Commercial	$885.42
Rate for Payer: BCBS Complete	$458.03
Rate for Payer: BCBS Trust/PPO	$72.38
Rate for Payer: Cash Price	$1,524.80
Rate for Payer: Cash Price	$1,524.80
Rate for Payer: Meridian Medicaid	$458.03
Rate for Payer: Priority Health Choice Medicaid	$436.22
Rate for Payer: Priority Health Cigna Priority Health	$1,334.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,033.05
Rate for Payer: Priority Health Narrow Network	$1,033.05
Rate for Payer: Priority Health SBD	$1,033.05
Rate for Payer: UMR Bronson Commercial	$876.76

PR PERQ THRMBC/NFS DIAL CIRCUIT TCAT PLMT IV STENT

Professional

Both

$1,512.00

Service Code	HCPCS 36906
Min. Negotiated Rate	$316.52
Max. Negotiated Rate	$1,420.60
Rate for Payer: Aetna Commercial	$685.46
Rate for Payer: BCBS Complete	$332.35
Rate for Payer: BCBS Trust/PPO	$1,420.60
Rate for Payer: Cash Price	$1,209.60
Rate for Payer: Cash Price	$1,209.60
Rate for Payer: Meridian Medicaid	$332.35
Rate for Payer: Priority Health Choice Medicaid	$316.52
Rate for Payer: Priority Health Cigna Priority Health	$1,058.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$791.02
Rate for Payer: Priority Health Narrow Network	$791.02
Rate for Payer: Priority Health SBD	$791.02
Rate for Payer: UMR Bronson Commercial	$695.52

PR PERQ THRMBC/NFS DIAL CIRCUIT TRLUML BALO ANGIOP

Professional

Both

$1,296.00

Service Code	HCPCS 36905
Min. Negotiated Rate	$274.13
Max. Negotiated Rate	$1,385.73
Rate for Payer: Aetna Commercial	$594.60
Rate for Payer: BCBS Complete	$287.84
Rate for Payer: BCBS Trust/PPO	$1,385.73
Rate for Payer: Cash Price	$1,036.80
Rate for Payer: Cash Price	$1,036.80
Rate for Payer: Meridian Medicaid	$287.84
Rate for Payer: Priority Health Choice Medicaid	$274.13
Rate for Payer: Priority Health Cigna Priority Health	$907.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$686.22
Rate for Payer: Priority Health Narrow Network	$686.22
Rate for Payer: Priority Health SBD	$686.22
Rate for Payer: UMR Bronson Commercial	$596.16

PR PERQ THRMBC/NFS DIALYSIS CIRCUIT IMG DX ANGRPH

Professional

Both

$870.00

Service Code	HCPCS 36904
Min. Negotiated Rate	$228.34
Max. Negotiated Rate	$1,699.01
Rate for Payer: Aetna Commercial	$493.49
Rate for Payer: BCBS Complete	$239.76
Rate for Payer: BCBS Trust/PPO	$1,699.01
Rate for Payer: Cash Price	$696.00
Rate for Payer: Cash Price	$696.00
Rate for Payer: Meridian Medicaid	$239.76
Rate for Payer: Priority Health Choice Medicaid	$228.34
Rate for Payer: Priority Health Cigna Priority Health	$609.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$570.79
Rate for Payer: Priority Health Narrow Network	$570.79
Rate for Payer: Priority Health SBD	$570.79
Rate for Payer: UMR Bronson Commercial	$400.20

PR PERQ VERT AGMNTJ CAVITY CRTJ UNI/BI CANNULATION

Professional

Both

$1,516.00

Service Code	HCPCS 22513
Min. Negotiated Rate	$219.77
Max. Negotiated Rate	$1,061.20
Rate for Payer: Aetna Commercial	$684.44
Rate for Payer: BCBS Complete	$340.17
Rate for Payer: BCBS Trust/PPO	$219.77
Rate for Payer: Cash Price	$1,212.80
Rate for Payer: Cash Price	$1,212.80
Rate for Payer: Meridian Medicaid	$340.17
Rate for Payer: Priority Health Choice Medicaid	$323.97
Rate for Payer: Priority Health Cigna Priority Health	$1,061.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$773.63
Rate for Payer: Priority Health Narrow Network	$773.63
Rate for Payer: Priority Health SBD	$773.63
Rate for Payer: UMR Bronson Commercial	$697.36

PR PERQ VERT AGMNTJ CAVITY CRTJ UNI/BI CANNULJ EACH

Professional

Both

$790.00

Service Code	HCPCS 22515
Min. Negotiated Rate	$57.48
Max. Negotiated Rate	$553.00
Rate for Payer: Aetna Commercial	$294.64
Rate for Payer: BCBS Complete	$144.26
Rate for Payer: BCBS Trust/PPO	$57.48
Rate for Payer: Cash Price	$632.00
Rate for Payer: Cash Price	$632.00
Rate for Payer: Meridian Medicaid	$144.26
Rate for Payer: Priority Health Choice Medicaid	$137.39
Rate for Payer: Priority Health Cigna Priority Health	$553.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$329.88
Rate for Payer: Priority Health Narrow Network	$329.88
Rate for Payer: Priority Health SBD	$329.88
Rate for Payer: UMR Bronson Commercial	$363.40

PR PERQ VERT AGMNTJ CAVITY CRTJ UNI/BI CANNULJ LMBR

Professional

Both

$1,416.00

Service Code	HCPCS 22514
Min. Negotiated Rate	$302.03
Max. Negotiated Rate	$3,205.12
Rate for Payer: Aetna Commercial	$638.90
Rate for Payer: BCBS Complete	$317.13
Rate for Payer: BCBS Trust/PPO	$3,205.12
Rate for Payer: Cash Price	$1,132.80
Rate for Payer: Cash Price	$1,132.80
Rate for Payer: Meridian Medicaid	$317.13
Rate for Payer: Priority Health Choice Medicaid	$302.03
Rate for Payer: Priority Health Cigna Priority Health	$991.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$721.55
Rate for Payer: Priority Health Narrow Network	$721.55
Rate for Payer: Priority Health SBD	$721.55
Rate for Payer: UMR Bronson Commercial	$651.36

PR PERQ VERTEBROPLASTY UNI/BI INJECTION LUMBOSACRAL

Professional

Both

$1,036.00

Service Code	HCPCS 22511
Min. Negotiated Rate	$190.19
Max. Negotiated Rate	$725.20
Rate for Payer: Aetna Commercial	$541.34
Rate for Payer: BCBS Complete	$270.16
Rate for Payer: BCBS Trust/PPO	$190.19
Rate for Payer: Cash Price	$828.80
Rate for Payer: Cash Price	$828.80
Rate for Payer: Meridian Medicaid	$270.16
Rate for Payer: Priority Health Choice Medicaid	$257.30
Rate for Payer: Priority Health Cigna Priority Health	$725.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$614.31
Rate for Payer: Priority Health Narrow Network	$614.31
Rate for Payer: Priority Health SBD	$614.31
Rate for Payer: UMR Bronson Commercial	$476.56

PR PERQ VERTEBROPLASTY UNI/BI INJX CERVICOTHORACIC

Professional

Both

$3,354.00

Service Code	HCPCS 22510
Min. Negotiated Rate	$273.28
Max. Negotiated Rate	$2,347.80
Rate for Payer: Aetna Commercial	$576.08
Rate for Payer: BCBS Complete	$286.94
Rate for Payer: BCBS Trust/PPO	$825.51
Rate for Payer: Cash Price	$2,683.20
Rate for Payer: Cash Price	$2,683.20
Rate for Payer: Meridian Medicaid	$286.94
Rate for Payer: Priority Health Choice Medicaid	$273.28
Rate for Payer: Priority Health Cigna Priority Health	$2,347.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$654.65
Rate for Payer: Priority Health Narrow Network	$654.65
Rate for Payer: Priority Health SBD	$654.65
Rate for Payer: UMR Bronson Commercial	$1,542.84

Know your out-of-pocket cost for care.

All Charges