Bronson Methodist Hospital

All Charges

Charge

Type

Setting

Price

PR PORTOENETEROSTOMY

Professional

Both

$4,721.00

Service Code	HCPCS 47701
Min. Negotiated Rate	$362.41
Max. Negotiated Rate	$3,304.70
Rate for Payer: Aetna Commercial	$2,356.00
Rate for Payer: BCBS Complete	$1,163.87
Rate for Payer: BCBS Trust/PPO	$362.41
Rate for Payer: Cash Price	$3,776.80
Rate for Payer: Cash Price	$3,776.80
Rate for Payer: Meridian Medicaid	$1,163.87
Rate for Payer: Priority Health Choice Medicaid	$1,108.45
Rate for Payer: Priority Health Cigna Priority Health	$3,304.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$3,049.23
Rate for Payer: Priority Health Narrow Network	$3,049.23
Rate for Payer: Priority Health SBD	$3,049.23
Rate for Payer: UMR Bronson Commercial	$2,171.66

PR POSITIONAL NYSTAGMUS TEST

Professional

Both

$41.00

Service Code	HCPCS 92542
Min. Negotiated Rate	$5.85
Max. Negotiated Rate	$1,840.07
Rate for Payer: Aetna Commercial	$32.34
Rate for Payer: BCBS Complete	$16.40
Rate for Payer: BCBS Trust/PPO	$1,840.07
Rate for Payer: Cash Price	$32.80
Rate for Payer: Cash Price	$32.80
Rate for Payer: Priority Health Cigna Priority Health	$28.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$5.85
Rate for Payer: Priority Health Narrow Network	$5.85
Rate for Payer: Priority Health SBD	$38.62
Rate for Payer: UMR Bronson Commercial	$18.86

PR POST-CATARACT LASER SURGERY

Professional

Both

$563.00

Service Code	HCPCS 66821
Min. Negotiated Rate	$197.88
Max. Negotiated Rate	$538.00
Rate for Payer: Aetna Commercial	$402.65
Rate for Payer: BCBS Complete	$207.77
Rate for Payer: BCBS Trust/PPO	$417.89
Rate for Payer: Cash Price	$450.40
Rate for Payer: Cash Price	$450.40
Rate for Payer: Meridian Medicaid	$207.77
Rate for Payer: Priority Health Choice Medicaid	$197.88
Rate for Payer: Priority Health Cigna Priority Health	$394.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$538.00
Rate for Payer: Priority Health Narrow Network	$538.00
Rate for Payer: Priority Health SBD	$538.00
Rate for Payer: UMR Bronson Commercial	$258.98

PR POST COLPORRHAPHY RECTOCELE W/WO PERINEORRHAPHY

Professional

Both

$1,379.00

Service Code	HCPCS 57250
Min. Negotiated Rate	$395.97
Max. Negotiated Rate	$1,809.43
Rate for Payer: Aetna Commercial	$731.56
Rate for Payer: BCBS Complete	$415.77
Rate for Payer: BCBS Trust/PPO	$1,809.43
Rate for Payer: Cash Price	$1,103.20
Rate for Payer: Cash Price	$1,103.20
Rate for Payer: Meridian Medicaid	$415.77
Rate for Payer: Priority Health Choice Medicaid	$395.97
Rate for Payer: Priority Health Cigna Priority Health	$965.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$875.83
Rate for Payer: Priority Health Narrow Network	$875.83
Rate for Payer: Priority Health SBD	$875.83
Rate for Payer: UMR Bronson Commercial	$634.34

PR POSTERIOR NON-SEGMENTAL INSTRUMENTATION

Professional

Both

$3,268.00

Service Code	HCPCS 22840
Min. Negotiated Rate	$481.38
Max. Negotiated Rate	$21,897.63
Rate for Payer: Aetna Commercial	$1,021.35
Rate for Payer: BCBS Complete	$505.45
Rate for Payer: BCBS Trust/PPO	$21,897.63
Rate for Payer: Cash Price	$2,614.40
Rate for Payer: Cash Price	$2,614.40
Rate for Payer: Meridian Medicaid	$505.45
Rate for Payer: Priority Health Choice Medicaid	$481.38
Rate for Payer: Priority Health Cigna Priority Health	$2,287.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,151.52
Rate for Payer: Priority Health Narrow Network	$1,151.52
Rate for Payer: Priority Health SBD	$1,151.52
Rate for Payer: UMR Bronson Commercial	$1,503.28

PR POSTERIOR SEGMENTAL INSTRUMENTATION 13/> VRT SE

Professional

Both

$3,852.00

Service Code	HCPCS 22844
Min. Negotiated Rate	$53.49
Max. Negotiated Rate	$2,696.40
Rate for Payer: Aetna Commercial	$1,328.64
Rate for Payer: BCBS Complete	$656.42
Rate for Payer: BCBS Trust/PPO	$53.49
Rate for Payer: Cash Price	$3,081.60
Rate for Payer: Cash Price	$3,081.60
Rate for Payer: Meridian Medicaid	$656.42
Rate for Payer: Priority Health Choice Medicaid	$625.16
Rate for Payer: Priority Health Cigna Priority Health	$2,696.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,496.20
Rate for Payer: Priority Health Narrow Network	$1,496.20
Rate for Payer: Priority Health SBD	$1,496.20
Rate for Payer: UMR Bronson Commercial	$1,771.92

PR POSTERIOR SEGMENTAL INSTRUMENTATION 3-6 VRT SEG

Professional

Both

$3,647.00

Service Code	HCPCS 22842
Min. Negotiated Rate	$483.43
Max. Negotiated Rate	$2,552.90
Rate for Payer: Aetna Commercial	$1,025.97
Rate for Payer: BCBS Complete	$510.14
Rate for Payer: BCBS Trust/PPO	$483.43
Rate for Payer: Cash Price	$2,917.60
Rate for Payer: Cash Price	$2,917.60
Rate for Payer: Meridian Medicaid	$510.14
Rate for Payer: Priority Health Choice Medicaid	$485.85
Rate for Payer: Priority Health Cigna Priority Health	$2,552.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,160.20
Rate for Payer: Priority Health Narrow Network	$1,160.20
Rate for Payer: Priority Health SBD	$1,160.20
Rate for Payer: UMR Bronson Commercial	$1,677.62

PR POSTERIOR SEGMENTAL INSTRUMENTATION 7-12 VRT SEG

Professional

Both

$4,011.00

Service Code	HCPCS 22843
Min. Negotiated Rate	$145.43
Max. Negotiated Rate	$2,807.70
Rate for Payer: Aetna Commercial	$1,097.80
Rate for Payer: BCBS Complete	$546.38
Rate for Payer: BCBS Trust/PPO	$145.43
Rate for Payer: Cash Price	$3,208.80
Rate for Payer: Cash Price	$3,208.80
Rate for Payer: Meridian Medicaid	$546.38
Rate for Payer: Priority Health Choice Medicaid	$520.36
Rate for Payer: Priority Health Cigna Priority Health	$2,807.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,241.91
Rate for Payer: Priority Health Narrow Network	$1,241.91
Rate for Payer: Priority Health SBD	$1,241.91
Rate for Payer: UMR Bronson Commercial	$1,845.06

PR POSTPARTUM CARE ONLY SEPARATE PROCEDURE

Professional

Both

$320.00

Service Code	HCPCS 59430
Min. Negotiated Rate	$23.25
Max. Negotiated Rate	$254.02
Rate for Payer: Aetna Commercial	$198.09
Rate for Payer: BCBS Complete	$174.81
Rate for Payer: BCBS Trust/PPO	$23.25
Rate for Payer: Cash Price	$256.00
Rate for Payer: Cash Price	$256.00
Rate for Payer: Meridian Medicaid	$174.81
Rate for Payer: Priority Health Choice Medicaid	$166.49
Rate for Payer: Priority Health Cigna Priority Health	$224.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$254.02
Rate for Payer: Priority Health Narrow Network	$254.02
Rate for Payer: Priority Health SBD	$254.02
Rate for Payer: UMR Bronson Commercial	$147.20

PR POST TIB NEUROSTIMULATION PRQ NEEDLE ELECTRODE

Professional

Both

$226.00

Service Code	HCPCS 64566
Min. Negotiated Rate	$19.17
Max. Negotiated Rate	$861.13
Rate for Payer: Aetna Commercial	$39.89
Rate for Payer: BCBS Complete	$20.13
Rate for Payer: BCBS Trust/PPO	$861.13
Rate for Payer: Cash Price	$180.80
Rate for Payer: Cash Price	$180.80
Rate for Payer: Meridian Medicaid	$20.13
Rate for Payer: Priority Health Choice Medicaid	$19.17
Rate for Payer: Priority Health Cigna Priority Health	$158.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$50.39
Rate for Payer: Priority Health Narrow Network	$50.39
Rate for Payer: Priority Health SBD	$50.39
Rate for Payer: UMR Bronson Commercial	$103.96

PR POTASSIUM HYDROXIDE PREPS

Professional

Both

$22.00

Service Code	HCPCS Q0112
Min. Negotiated Rate	$5.54
Max. Negotiated Rate	$334.41
Rate for Payer: Aetna Commercial	$5.54
Rate for Payer: BCBS Complete	$8.80
Rate for Payer: BCBS Trust/PPO	$334.41
Rate for Payer: Cash Price	$17.60
Rate for Payer: Cash Price	$17.60
Rate for Payer: Priority Health Cigna Priority Health	$15.40
Rate for Payer: UMR Bronson Commercial	$10.12

PR PPPS, INITIAL VISIT

Professional

Both

$254.00

Service Code	HCPCS G0438
Min. Negotiated Rate	$101.60
Max. Negotiated Rate	$387.24
Rate for Payer: Aetna Commercial	$164.23
Rate for Payer: BCBS Complete	$101.60
Rate for Payer: BCBS Trust/PPO	$387.24
Rate for Payer: Cash Price	$203.20
Rate for Payer: Cash Price	$203.20
Rate for Payer: Priority Health Cigna Priority Health	$177.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$214.49
Rate for Payer: Priority Health Narrow Network	$214.49
Rate for Payer: Priority Health SBD	$214.49
Rate for Payer: UMR Bronson Commercial	$116.84

PR PPPS, SUBSEQ VISIT

Professional

Both

$172.00

Service Code	HCPCS G0439
Min. Negotiated Rate	$68.80
Max. Negotiated Rate	$728.00
Rate for Payer: Aetna Commercial	$129.30
Rate for Payer: BCBS Complete	$68.80
Rate for Payer: BCBS Trust/PPO	$728.00
Rate for Payer: Cash Price	$137.60
Rate for Payer: Cash Price	$137.60
Rate for Payer: Priority Health Cigna Priority Health	$120.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$167.75
Rate for Payer: Priority Health Narrow Network	$167.75
Rate for Payer: Priority Health SBD	$167.75
Rate for Payer: UMR Bronson Commercial	$79.12

PR PPSV23 VACCINE 2 YRS OR OLDER FOR SUBQ/IM USE

Professional

Both

$143.00

Service Code	HCPCS 90732
Min. Negotiated Rate	$57.20
Max. Negotiated Rate	$138.56
Rate for Payer: Aetna Commercial	$133.47
Rate for Payer: BCBS Complete	$57.20
Rate for Payer: BCBS Trust/PPO	$138.56
Rate for Payer: Cash Price	$114.40
Rate for Payer: Cash Price	$114.40
Rate for Payer: Priority Health Cigna Priority Health	$100.10
Rate for Payer: UMR Bronson Commercial	$65.78

PR PRCTECT CMBN ABDOMINOPRNL PULL-THRU PX

Professional

Both

$4,561.00

Service Code	HCPCS 45112
Min. Negotiated Rate	$234.04
Max. Negotiated Rate	$3,192.70
Rate for Payer: Aetna Commercial	$2,494.03
Rate for Payer: BCBS Complete	$1,203.91
Rate for Payer: BCBS Trust/PPO	$234.04
Rate for Payer: Cash Price	$3,648.80
Rate for Payer: Cash Price	$3,648.80
Rate for Payer: Meridian Medicaid	$1,203.91
Rate for Payer: Priority Health Choice Medicaid	$1,146.58
Rate for Payer: Priority Health Cigna Priority Health	$3,192.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$3,153.89
Rate for Payer: Priority Health Narrow Network	$3,153.89
Rate for Payer: Priority Health SBD	$3,153.89
Rate for Payer: UMR Bronson Commercial	$2,098.06

PR PRCTECT COMPL CMBN ABDOMINOPRNL W/CLST

Professional

Both

$4,632.00

Service Code	HCPCS 45110
Min. Negotiated Rate	$389.36
Max. Negotiated Rate	$3,242.40
Rate for Payer: Aetna Commercial	$2,449.99
Rate for Payer: BCBS Complete	$1,209.73
Rate for Payer: BCBS Trust/PPO	$389.36
Rate for Payer: Cash Price	$3,705.60
Rate for Payer: Cash Price	$3,705.60
Rate for Payer: Meridian Medicaid	$1,209.73
Rate for Payer: Priority Health Choice Medicaid	$1,152.12
Rate for Payer: Priority Health Cigna Priority Health	$3,242.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$3,176.24
Rate for Payer: Priority Health Narrow Network	$3,176.24
Rate for Payer: Priority Health SBD	$3,176.24
Rate for Payer: UMR Bronson Commercial	$2,130.72

PR PRCTECT COMPL W/PULL-THRU PX & ANASTOMOSIS

Professional

Both

$4,895.00

Service Code	HCPCS 45120
Min. Negotiated Rate	$234.57
Max. Negotiated Rate	$3,426.50
Rate for Payer: Aetna Commercial	$2,162.46
Rate for Payer: BCBS Complete	$1,073.74
Rate for Payer: BCBS Trust/PPO	$234.57
Rate for Payer: Cash Price	$3,916.00
Rate for Payer: Cash Price	$3,916.00
Rate for Payer: Meridian Medicaid	$1,073.74
Rate for Payer: Priority Health Choice Medicaid	$1,022.61
Rate for Payer: Priority Health Cigna Priority Health	$3,426.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,809.33
Rate for Payer: Priority Health Narrow Network	$2,809.33
Rate for Payer: Priority Health SBD	$2,809.33
Rate for Payer: UMR Bronson Commercial	$2,251.70

PR PRCTECT COMPL W/STOT/TOT COLCT W/MLT BXS

Professional

Both

$4,804.00

Service Code	HCPCS 45121
Min. Negotiated Rate	$188.07
Max. Negotiated Rate	$3,362.80
Rate for Payer: Aetna Commercial	$2,361.59
Rate for Payer: BCBS Complete	$1,171.71
Rate for Payer: BCBS Trust/PPO	$188.07
Rate for Payer: Cash Price	$3,843.20
Rate for Payer: Cash Price	$3,843.20
Rate for Payer: Meridian Medicaid	$1,171.71
Rate for Payer: Priority Health Choice Medicaid	$1,115.91
Rate for Payer: Priority Health Cigna Priority Health	$3,362.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$3,065.10
Rate for Payer: Priority Health Narrow Network	$3,065.10
Rate for Payer: Priority Health SBD	$3,065.10
Rate for Payer: UMR Bronson Commercial	$2,209.84

PR PRCTECT PRTL RESCJ RECTUM TABDL APPR

Professional

Both

$1,934.00

Service Code	HCPCS 45111
Min. Negotiated Rate	$283.70
Max. Negotiated Rate	$1,896.21
Rate for Payer: Aetna Commercial	$1,458.02
Rate for Payer: BCBS Complete	$727.99
Rate for Payer: BCBS Trust/PPO	$283.70
Rate for Payer: Cash Price	$1,547.20
Rate for Payer: Cash Price	$1,547.20
Rate for Payer: Meridian Medicaid	$727.99
Rate for Payer: Priority Health Choice Medicaid	$693.32
Rate for Payer: Priority Health Cigna Priority Health	$1,353.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,896.21
Rate for Payer: Priority Health Narrow Network	$1,896.21
Rate for Payer: Priority Health SBD	$1,896.21
Rate for Payer: UMR Bronson Commercial	$889.64

PR PRCTECT PRTL W/ANAST ABDL & TRANSSAC APPROACH

Professional

Both

$3,195.00

Service Code	HCPCS 45114
Min. Negotiated Rate	$86.17
Max. Negotiated Rate	$3,185.05
Rate for Payer: Aetna Commercial	$2,460.29
Rate for Payer: BCBS Complete	$1,216.66
Rate for Payer: BCBS Trust/PPO	$86.17
Rate for Payer: Cash Price	$2,556.00
Rate for Payer: Cash Price	$2,556.00
Rate for Payer: Meridian Medicaid	$1,216.66
Rate for Payer: Priority Health Choice Medicaid	$1,158.72
Rate for Payer: Priority Health Cigna Priority Health	$2,236.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$3,185.05
Rate for Payer: Priority Health Narrow Network	$3,185.05
Rate for Payer: Priority Health SBD	$3,185.05
Rate for Payer: UMR Bronson Commercial	$1,469.70

PR PRCTECT PRTL W/ANAST TRANSSAC APPR ONLY

Professional

Both

$3,736.00

Service Code	HCPCS 45116
Min. Negotiated Rate	$187.02
Max. Negotiated Rate	$2,687.04
Rate for Payer: Aetna Commercial	$2,057.79
Rate for Payer: BCBS Complete	$1,026.77
Rate for Payer: BCBS Trust/PPO	$187.02
Rate for Payer: Cash Price	$2,988.80
Rate for Payer: Cash Price	$2,988.80
Rate for Payer: Meridian Medicaid	$1,026.77
Rate for Payer: Priority Health Choice Medicaid	$977.88
Rate for Payer: Priority Health Cigna Priority Health	$2,615.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,687.04
Rate for Payer: Priority Health Narrow Network	$2,687.04
Rate for Payer: Priority Health SBD	$2,687.04
Rate for Payer: UMR Bronson Commercial	$1,718.56

PR PRCTECT PRTL W/MUCOSEC ILEOANAL ANAST RSVR

Professional

Both

$5,348.00

Service Code	HCPCS 45113
Min. Negotiated Rate	$234.57
Max. Negotiated Rate	$3,743.60
Rate for Payer: Aetna Commercial	$2,493.80
Rate for Payer: BCBS Complete	$1,237.68
Rate for Payer: BCBS Trust/PPO	$234.57
Rate for Payer: Cash Price	$4,278.40
Rate for Payer: Cash Price	$4,278.40
Rate for Payer: Meridian Medicaid	$1,237.68
Rate for Payer: Priority Health Choice Medicaid	$1,178.74
Rate for Payer: Priority Health Cigna Priority Health	$3,743.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$3,245.01
Rate for Payer: Priority Health Narrow Network	$3,245.01
Rate for Payer: Priority Health SBD	$3,245.01
Rate for Payer: UMR Bronson Commercial	$2,460.08

PR PRCTECT PRTL W/O ANAST PRNL APPR

Professional

Both

$2,987.00

Service Code	HCPCS 45123
Min. Negotiated Rate	$707.59
Max. Negotiated Rate	$2,090.90
Rate for Payer: Aetna Commercial	$1,489.82
Rate for Payer: BCBS Complete	$742.97
Rate for Payer: BCBS Trust/PPO	$2,046.11
Rate for Payer: Cash Price	$2,389.60
Rate for Payer: Cash Price	$2,389.60
Rate for Payer: Meridian Medicaid	$742.97
Rate for Payer: Priority Health Choice Medicaid	$707.59
Rate for Payer: Priority Health Cigna Priority Health	$2,090.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,951.49
Rate for Payer: Priority Health Narrow Network	$1,951.49
Rate for Payer: Priority Health SBD	$1,951.49
Rate for Payer: UMR Bronson Commercial	$1,374.02

PR PREDNISONE IR OR DR ORAL 1MG

Professional

Both

$0.50

Service Code	HCPCS J7512
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.35
Rate for Payer: Aetna Commercial	$0.01
Rate for Payer: BCBS Complete	$0.20
Rate for Payer: BCBS Trust/PPO	$0.01
Rate for Payer: Cash Price	$0.40
Rate for Payer: Cash Price	$0.40
Rate for Payer: Priority Health Cigna Priority Health	$0.35
Rate for Payer: UMR Bronson Commercial	$0.23

PR PREDNISONE ORAL

Professional

Both

$1.00

Service Code	HCPCS J7506
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.70
Rate for Payer: BCBS Complete	$0.40
Rate for Payer: Cash Price	$0.80
Rate for Payer: Priority Health Cigna Priority Health	$0.70
Rate for Payer: UMR Bronson Commercial	$0.46

Know your out-of-pocket cost for care.

All Charges