Bronson Methodist Hospital

All Charges

Charge

Type

Setting

Price

PR PLMT PROX XTN PROSTH EVASC RPR DTA 1ST XTN

Professional

Both

$2,233.00

Service Code	HCPCS 33883
Min. Negotiated Rate	$693.95
Max. Negotiated Rate	$1,726.74
Rate for Payer: Aetna Commercial	$1,495.47
Rate for Payer: BCBS Complete	$728.65
Rate for Payer: BCBS Trust/PPO	$1,099.39
Rate for Payer: Cash Price	$1,786.40
Rate for Payer: Cash Price	$1,786.40
Rate for Payer: Meridian Medicaid	$728.65
Rate for Payer: Priority Health Choice Medicaid	$693.95
Rate for Payer: Priority Health Cigna Priority Health	$1,563.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,726.74
Rate for Payer: Priority Health Narrow Network	$1,726.74
Rate for Payer: Priority Health SBD	$1,726.74
Rate for Payer: UMR Bronson Commercial	$1,027.18

PR PLMT PROX XTN PROSTH EVASC RPR DTA EA PROX XTN

Professional

Both

$860.00

Service Code	HCPCS 33884
Min. Negotiated Rate	$245.38
Max. Negotiated Rate	$1,597.58
Rate for Payer: Aetna Commercial	$532.47
Rate for Payer: BCBS Complete	$257.65
Rate for Payer: BCBS Trust/PPO	$1,597.58
Rate for Payer: Cash Price	$688.00
Rate for Payer: Cash Price	$688.00
Rate for Payer: Meridian Medicaid	$257.65
Rate for Payer: Priority Health Choice Medicaid	$245.38
Rate for Payer: Priority Health Cigna Priority Health	$602.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$610.70
Rate for Payer: Priority Health Narrow Network	$610.70
Rate for Payer: Priority Health SBD	$610.70
Rate for Payer: UMR Bronson Commercial	$395.60

PR PLMT URTRL STENT PRQ PRE-EXISTING NFROS TRACT

Professional

Both

$552.00

Service Code	HCPCS 50693
Min. Negotiated Rate	$126.31
Max. Negotiated Rate	$3,785.27
Rate for Payer: Aetna Commercial	$260.02
Rate for Payer: BCBS Complete	$132.63
Rate for Payer: BCBS Trust/PPO	$3,785.27
Rate for Payer: Cash Price	$441.60
Rate for Payer: Cash Price	$441.60
Rate for Payer: Meridian Medicaid	$132.63
Rate for Payer: Priority Health Choice Medicaid	$126.31
Rate for Payer: Priority Health Cigna Priority Health	$386.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$320.43
Rate for Payer: Priority Health Narrow Network	$320.43
Rate for Payer: Priority Health SBD	$320.43
Rate for Payer: UMR Bronson Commercial	$253.92

PR PLMT VEIN PATCH/CUFF DSTL ANAST BYP CONDUIT

Professional

Both

$434.00

Service Code	HCPCS 35685
Min. Negotiated Rate	$122.90
Max. Negotiated Rate	$2,230.82
Rate for Payer: Aetna Commercial	$268.12
Rate for Payer: BCBS Complete	$129.04
Rate for Payer: BCBS Trust/PPO	$2,230.82
Rate for Payer: Cash Price	$347.20
Rate for Payer: Cash Price	$347.20
Rate for Payer: Meridian Medicaid	$129.04
Rate for Payer: Priority Health Choice Medicaid	$122.90
Rate for Payer: Priority Health Cigna Priority Health	$303.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$306.41
Rate for Payer: Priority Health Narrow Network	$306.41
Rate for Payer: Priority Health SBD	$306.41
Rate for Payer: UMR Bronson Commercial	$199.64

PR PLNNING PT SPEC FENEST VISCERAL AORTIC GRAFT

Professional

Both

$200.00

Service Code	HCPCS 34839
Min. Negotiated Rate	$80.00
Max. Negotiated Rate	$1,815.77
Rate for Payer: Aetna Commercial	$240.00
Rate for Payer: BCBS Complete	$80.00
Rate for Payer: BCBS Trust/PPO	$1,815.77
Rate for Payer: Cash Price	$160.00
Rate for Payer: Cash Price	$160.00
Rate for Payer: Priority Health Cigna Priority Health	$140.00
Rate for Payer: UMR Bronson Commercial	$92.00

PR PL REJUV/PERFECT

Professional

Both

$120.00

Service Code	HCPCS 00071
Hospital Revenue Code	990
Min. Negotiated Rate	$48.00
Max. Negotiated Rate	$84.00
Rate for Payer: BCBS Complete	$48.00
Rate for Payer: Cash Price	$96.00
Rate for Payer: Priority Health Cigna Priority Health	$84.00
Rate for Payer: UMR Bronson Commercial	$55.20

PR PLSTC RPR CL LIP/NSL DFRM SEC RECRTJ DFCT & RECL

Professional

Both

$1,846.00

Service Code	HCPCS 40720
Min. Negotiated Rate	$656.04
Max. Negotiated Rate	$1,805.08
Rate for Payer: Aetna Commercial	$1,363.02
Rate for Payer: BCBS Complete	$688.84
Rate for Payer: BCBS Trust/PPO	$1,487.69
Rate for Payer: Cash Price	$1,476.80
Rate for Payer: Cash Price	$1,476.80
Rate for Payer: Meridian Medicaid	$688.84
Rate for Payer: Priority Health Choice Medicaid	$656.04
Rate for Payer: Priority Health Cigna Priority Health	$1,292.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,805.08
Rate for Payer: Priority Health Narrow Network	$1,805.08
Rate for Payer: Priority Health SBD	$1,805.08
Rate for Payer: UMR Bronson Commercial	$849.16

PR PLSTC RPR SALIVARY DUX SIALODOCHOPLASTY PRIM

Professional

Both

$855.00

Service Code	HCPCS 42500
Min. Negotiated Rate	$223.01
Max. Negotiated Rate	$1,052.90
Rate for Payer: Aetna Commercial	$454.70
Rate for Payer: BCBS Complete	$234.16
Rate for Payer: BCBS Trust/PPO	$1,052.90
Rate for Payer: Cash Price	$684.00
Rate for Payer: Cash Price	$684.00
Rate for Payer: Meridian Medicaid	$234.16
Rate for Payer: Priority Health Choice Medicaid	$223.01
Rate for Payer: Priority Health Cigna Priority Health	$598.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$612.66
Rate for Payer: Priority Health Narrow Network	$612.66
Rate for Payer: Priority Health SBD	$612.66
Rate for Payer: UMR Bronson Commercial	$393.30

PR PLSTC RPR SALIVARY DUX SIALODOCHOPLASTY SEC/COMP

Professional

Both

$1,090.00

Service Code	HCPCS 42505
Min. Negotiated Rate	$296.07
Max. Negotiated Rate	$812.58
Rate for Payer: Aetna Commercial	$603.00
Rate for Payer: BCBS Complete	$310.87
Rate for Payer: BCBS Trust/PPO	$318.04
Rate for Payer: Cash Price	$872.00
Rate for Payer: Cash Price	$872.00
Rate for Payer: Meridian Medicaid	$310.87
Rate for Payer: Priority Health Choice Medicaid	$296.07
Rate for Payer: Priority Health Cigna Priority Health	$763.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$812.58
Rate for Payer: Priority Health Narrow Network	$812.58
Rate for Payer: Priority Health SBD	$812.58
Rate for Payer: UMR Bronson Commercial	$501.40

PR PL VITALIZE

Professional

Both

$100.00

Service Code	HCPCS 00070
Hospital Revenue Code	990
Min. Negotiated Rate	$40.00
Max. Negotiated Rate	$70.00
Rate for Payer: BCBS Complete	$40.00
Rate for Payer: Cash Price	$80.00
Rate for Payer: Priority Health Cigna Priority Health	$70.00
Rate for Payer: UMR Bronson Commercial	$46.00

PR PNCRTECT DSTL STOT W/O PNCRTCOJEJUNOSTOMY

Professional

Both

$3,592.00

Service Code	HCPCS 48140
Min. Negotiated Rate	$1,000.67
Max. Negotiated Rate	$2,748.78
Rate for Payer: Aetna Commercial	$2,112.86
Rate for Payer: BCBS Complete	$1,050.70
Rate for Payer: BCBS Trust/PPO	$1,200.30
Rate for Payer: Cash Price	$2,873.60
Rate for Payer: Cash Price	$2,873.60
Rate for Payer: Meridian Medicaid	$1,050.70
Rate for Payer: Priority Health Choice Medicaid	$1,000.67
Rate for Payer: Priority Health Cigna Priority Health	$2,514.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,748.78
Rate for Payer: Priority Health Narrow Network	$2,748.78
Rate for Payer: Priority Health SBD	$2,748.78
Rate for Payer: UMR Bronson Commercial	$1,652.32

PR PNCRTECT PROX STOT W/PANCREATOJEJUNOSTOMY

Professional

Both

$5,453.00

Service Code	HCPCS 48150
Min. Negotiated Rate	$711.62
Max. Negotiated Rate	$5,455.20
Rate for Payer: Aetna Commercial	$4,213.34
Rate for Payer: BCBS Complete	$2,084.42
Rate for Payer: BCBS Trust/PPO	$711.62
Rate for Payer: Cash Price	$4,362.40
Rate for Payer: Cash Price	$4,362.40
Rate for Payer: Meridian Medicaid	$2,084.42
Rate for Payer: Priority Health Choice Medicaid	$1,985.16
Rate for Payer: Priority Health Cigna Priority Health	$3,817.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$5,455.20
Rate for Payer: Priority Health Narrow Network	$5,455.20
Rate for Payer: Priority Health SBD	$5,455.20
Rate for Payer: UMR Bronson Commercial	$2,508.38

PR PNCRTECT W/PANCREATOJEJUNOSTOMY

Professional

Both

$8,140.00

Service Code	HCPCS 48153
Min. Negotiated Rate	$747.02
Max. Negotiated Rate	$5,698.00
Rate for Payer: Aetna Commercial	$4,201.24
Rate for Payer: BCBS Complete	$2,075.69
Rate for Payer: BCBS Trust/PPO	$747.02
Rate for Payer: Cash Price	$6,512.00
Rate for Payer: Cash Price	$6,512.00
Rate for Payer: Meridian Medicaid	$2,075.69
Rate for Payer: Priority Health Choice Medicaid	$1,976.85
Rate for Payer: Priority Health Cigna Priority Health	$5,698.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$5,437.58
Rate for Payer: Priority Health Narrow Network	$5,437.58
Rate for Payer: Priority Health SBD	$5,437.58
Rate for Payer: UMR Bronson Commercial	$3,744.40

PR PNEUMOCOCCAL CONJ VACCINE 7 VALENT IM

Professional

Both

$114.00

Service Code	HCPCS 90669
Min. Negotiated Rate	$45.60
Max. Negotiated Rate	$79.80
Rate for Payer: BCBS Complete	$45.60
Rate for Payer: Cash Price	$91.20
Rate for Payer: Priority Health Cigna Priority Health	$79.80
Rate for Payer: UMR Bronson Commercial	$52.44

PR PNEUMONOLYSIS XTRPRIOSTEAL W/FILLING/PACKING PX

Professional

Both

$2,524.00

Service Code	HCPCS 32940
Min. Negotiated Rate	$777.45
Max. Negotiated Rate	$1,766.80
Rate for Payer: Aetna Commercial	$1,590.96
Rate for Payer: BCBS Complete	$816.32
Rate for Payer: BCBS Trust/PPO	$1,049.20
Rate for Payer: Cash Price	$2,019.20
Rate for Payer: Cash Price	$2,019.20
Rate for Payer: Meridian Medicaid	$816.32
Rate for Payer: Priority Health Choice Medicaid	$777.45
Rate for Payer: Priority Health Cigna Priority Health	$1,766.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,681.78
Rate for Payer: Priority Health Narrow Network	$1,681.78
Rate for Payer: Priority Health SBD	$1,681.78
Rate for Payer: UMR Bronson Commercial	$1,161.04

PR PNEUMONOSTOMY W/OPEN DRAINAGE ABSCESS/CYST

Professional

Both

$2,675.00

Service Code	HCPCS 32200
Min. Negotiated Rate	$721.86
Max. Negotiated Rate	$1,872.50
Rate for Payer: Aetna Commercial	$1,465.11
Rate for Payer: BCBS Complete	$757.95
Rate for Payer: BCBS Trust/PPO	$897.05
Rate for Payer: Cash Price	$2,140.00
Rate for Payer: Cash Price	$2,140.00
Rate for Payer: Meridian Medicaid	$757.95
Rate for Payer: Priority Health Choice Medicaid	$721.86
Rate for Payer: Priority Health Cigna Priority Health	$1,872.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,558.14
Rate for Payer: Priority Health Narrow Network	$1,558.14
Rate for Payer: Priority Health SBD	$1,558.14
Rate for Payer: UMR Bronson Commercial	$1,230.50

PR PNEUMOTHORAX THER INTRAPLEURAL INJECTION AIR

Professional

Both

$303.00

Service Code	HCPCS 32960
Min. Negotiated Rate	$56.87
Max. Negotiated Rate	$1,588.07
Rate for Payer: Aetna Commercial	$117.78
Rate for Payer: BCBS Complete	$59.71
Rate for Payer: BCBS Trust/PPO	$1,588.07
Rate for Payer: Cash Price	$242.40
Rate for Payer: Cash Price	$242.40
Rate for Payer: Meridian Medicaid	$59.71
Rate for Payer: Priority Health Choice Medicaid	$56.87
Rate for Payer: Priority Health Cigna Priority Health	$212.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$124.10
Rate for Payer: Priority Health Narrow Network	$124.10
Rate for Payer: Priority Health SBD	$124.10
Rate for Payer: UMR Bronson Commercial	$139.38

PR PNXR ASPIR HYDROCELE TUNICA VAGIS W/WO NJX MED

Professional

Both

$217.00

Service Code	HCPCS 55000
Min. Negotiated Rate	$53.89
Max. Negotiated Rate	$2,324.52
Rate for Payer: Aetna Commercial	$107.54
Rate for Payer: BCBS Complete	$56.58
Rate for Payer: BCBS Trust/PPO	$2,324.52
Rate for Payer: Cash Price	$173.60
Rate for Payer: Cash Price	$173.60
Rate for Payer: Meridian Medicaid	$56.58
Rate for Payer: Priority Health Choice Medicaid	$53.89
Rate for Payer: Priority Health Cigna Priority Health	$151.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$134.55
Rate for Payer: Priority Health Narrow Network	$134.55
Rate for Payer: Priority Health SBD	$134.55
Rate for Payer: UMR Bronson Commercial	$99.82

PR POLIOVIRUS VACCINE INACTIVATED SUBQ/IM

Professional

Both

$45.00

Service Code	HCPCS 90713
Min. Negotiated Rate	$18.00
Max. Negotiated Rate	$43.27
Rate for Payer: Aetna Commercial	$43.27
Rate for Payer: BCBS Complete	$18.00
Rate for Payer: BCBS Trust/PPO	$40.14
Rate for Payer: Cash Price	$36.00
Rate for Payer: Cash Price	$36.00
Rate for Payer: Priority Health Cigna Priority Health	$31.50
Rate for Payer: UMR Bronson Commercial	$20.70

PR POLLICIZATION DIGIT

Professional

Both

$2,714.00

Service Code	HCPCS 26550
Min. Negotiated Rate	$136.83
Max. Negotiated Rate	$2,543.55
Rate for Payer: Aetna Commercial	$2,222.53
Rate for Payer: BCBS Complete	$1,114.00
Rate for Payer: BCBS Trust/PPO	$136.83
Rate for Payer: Cash Price	$2,171.20
Rate for Payer: Cash Price	$2,171.20
Rate for Payer: Meridian Medicaid	$1,114.00
Rate for Payer: Priority Health Choice Medicaid	$1,060.95
Rate for Payer: Priority Health Cigna Priority Health	$1,899.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,543.55
Rate for Payer: Priority Health Narrow Network	$2,543.55
Rate for Payer: Priority Health SBD	$2,543.55
Rate for Payer: UMR Bronson Commercial	$1,248.44

PR POLYSOM 6/>YRS SLEEP 4/> ADDL PARAM ATTND

Professional

Both

$977.00

Service Code	HCPCS 95810
Min. Negotiated Rate	$155.85
Max. Negotiated Rate	$815.19
Rate for Payer: Aetna Commercial	$639.21
Rate for Payer: Aetna Commercial	$639.21
Rate for Payer: BCBS Complete	$390.80
Rate for Payer: BCBS Complete	$186.00
Rate for Payer: BCBS Trust/PPO	$634.49
Rate for Payer: BCBS Trust/PPO	$634.49
Rate for Payer: Cash Price	$372.00
Rate for Payer: Cash Price	$781.60
Rate for Payer: Cash Price	$781.60
Rate for Payer: Cash Price	$372.00
Rate for Payer: Priority Health Cigna Priority Health	$683.90
Rate for Payer: Priority Health Cigna Priority Health	$325.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$155.85
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$155.85
Rate for Payer: Priority Health Narrow Network	$155.85
Rate for Payer: Priority Health Narrow Network	$155.85
Rate for Payer: Priority Health SBD	$815.19
Rate for Payer: Priority Health SBD	$815.19
Rate for Payer: UMR Bronson Commercial	$449.42
Rate for Payer: UMR Bronson Commercial	$213.90

PR POLYSOM <6 YRS SLEEP STAGE 4/> ADDL PARAM ATTND

Professional

Both

$1,702.00

Service Code	HCPCS 95782
Min. Negotiated Rate	$162.59
Max. Negotiated Rate	$1,275.57
Rate for Payer: Aetna Commercial	$958.65
Rate for Payer: Aetna Commercial	$958.65
Rate for Payer: BCBS Complete	$101.20
Rate for Payer: BCBS Complete	$680.80
Rate for Payer: BCBS Trust/PPO	$567.92
Rate for Payer: BCBS Trust/PPO	$567.92
Rate for Payer: Cash Price	$202.40
Rate for Payer: Cash Price	$1,361.60
Rate for Payer: Cash Price	$202.40
Rate for Payer: Cash Price	$1,361.60
Rate for Payer: Priority Health Cigna Priority Health	$1,191.40
Rate for Payer: Priority Health Cigna Priority Health	$177.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$162.59
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$162.59
Rate for Payer: Priority Health Narrow Network	$162.59
Rate for Payer: Priority Health Narrow Network	$162.59
Rate for Payer: Priority Health SBD	$1,275.57
Rate for Payer: Priority Health SBD	$1,275.57
Rate for Payer: UMR Bronson Commercial	$782.92
Rate for Payer: UMR Bronson Commercial	$116.38

PR POLYSOM 6/>YRS SLEEP W/CPAP 4/> ADDL PARAM ATTND

Professional

Both

$492.00

Service Code	HCPCS 95811
Min. Negotiated Rate	$161.69
Max. Negotiated Rate	$1,013.28
Rate for Payer: Aetna Commercial	$667.17
Rate for Payer: Aetna Commercial	$667.17
Rate for Payer: BCBS Complete	$196.80
Rate for Payer: BCBS Complete	$488.80
Rate for Payer: BCBS Trust/PPO	$1,013.28
Rate for Payer: BCBS Trust/PPO	$1,013.28
Rate for Payer: Cash Price	$977.60
Rate for Payer: Cash Price	$977.60
Rate for Payer: Cash Price	$393.60
Rate for Payer: Cash Price	$393.60
Rate for Payer: Priority Health Cigna Priority Health	$855.40
Rate for Payer: Priority Health Cigna Priority Health	$344.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$161.69
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$161.69
Rate for Payer: Priority Health Narrow Network	$161.69
Rate for Payer: Priority Health Narrow Network	$161.69
Rate for Payer: Priority Health SBD	$852.92
Rate for Payer: Priority Health SBD	$852.92
Rate for Payer: UMR Bronson Commercial	$226.32
Rate for Payer: UMR Bronson Commercial	$562.12

PR POLYSOM <6 YRS SLEEP W/CPAP/BILVL VENT 4/> PARAM

Professional

Both

$1,817.00

Service Code	HCPCS 95783
Min. Negotiated Rate	$177.41
Max. Negotiated Rate	$1,351.48
Rate for Payer: Aetna Commercial	$1,016.43
Rate for Payer: Aetna Commercial	$1,016.43
Rate for Payer: BCBS Complete	$726.80
Rate for Payer: BCBS Complete	$110.40
Rate for Payer: BCBS Trust/PPO	$686.79
Rate for Payer: BCBS Trust/PPO	$686.79
Rate for Payer: Cash Price	$1,453.60
Rate for Payer: Cash Price	$1,453.60
Rate for Payer: Cash Price	$220.80
Rate for Payer: Cash Price	$220.80
Rate for Payer: Priority Health Cigna Priority Health	$1,271.90
Rate for Payer: Priority Health Cigna Priority Health	$193.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$177.41
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$177.41
Rate for Payer: Priority Health Narrow Network	$177.41
Rate for Payer: Priority Health Narrow Network	$177.41
Rate for Payer: Priority Health SBD	$1,351.48
Rate for Payer: Priority Health SBD	$1,351.48
Rate for Payer: UMR Bronson Commercial	$835.82
Rate for Payer: UMR Bronson Commercial	$126.96

PR POLYSOM ANY AGE SLEEP STAGE 1-3 ADDL PARAM ATTND

Professional

Both

$422.00

Service Code	HCPCS 95808
Min. Negotiated Rate	$109.15
Max. Negotiated Rate	$769.73
Rate for Payer: Aetna Commercial	$682.59
Rate for Payer: Aetna Commercial	$682.59
Rate for Payer: BCBS Complete	$168.80
Rate for Payer: BCBS Complete	$682.40
Rate for Payer: BCBS Trust/PPO	$769.73
Rate for Payer: BCBS Trust/PPO	$769.73
Rate for Payer: Cash Price	$337.60
Rate for Payer: Cash Price	$1,364.80
Rate for Payer: Cash Price	$1,364.80
Rate for Payer: Cash Price	$337.60
Rate for Payer: Priority Health Cigna Priority Health	$1,194.20
Rate for Payer: Priority Health Cigna Priority Health	$295.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$109.15
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$109.15
Rate for Payer: Priority Health Narrow Network	$109.15
Rate for Payer: Priority Health Narrow Network	$109.15
Rate for Payer: Priority Health SBD	$737.04
Rate for Payer: Priority Health SBD	$737.04
Rate for Payer: UMR Bronson Commercial	$784.76
Rate for Payer: UMR Bronson Commercial	$194.12

Know your out-of-pocket cost for care.

All Charges