Bronson Lakeview Hospital

All Charges

Charge

Type

Setting

Price

CHG CT PELVIS W/O CONTRAST MATERIAL

Professional

Both

$115.00

Service Code	HCPCS 72192
Min. Negotiated Rate	$57.50
Max. Negotiated Rate	$203.20
Rate for Payer: Aetna Commercial	$173.63
Rate for Payer: Aetna Medicare	$57.50
Rate for Payer: BCN Commercial	$201.68
Rate for Payer: Cash Price	$92.00
Rate for Payer: Cash Price	$92.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$86.25
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$203.20
Rate for Payer: Priority Health Narrow/Tiered Network	$203.20

CHG CT PELVIS W/O & W/CONTRAST MATERIAL

Professional

Both

$129.00

Service Code	HCPCS 72194
Min. Negotiated Rate	$64.50
Max. Negotiated Rate	$382.32
Rate for Payer: Aetna Commercial	$280.75
Rate for Payer: Aetna Medicare	$64.50
Rate for Payer: BCN Commercial	$379.46
Rate for Payer: Cash Price	$103.20
Rate for Payer: Cash Price	$103.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$96.75
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$382.32
Rate for Payer: Priority Health Narrow/Tiered Network	$382.32

CHG CT SOFT TISSUE NECK W/CONTRAST MATERIAL

Professional

Both

$147.00

Service Code	HCPCS 70491
Min. Negotiated Rate	$73.50
Max. Negotiated Rate	$280.97
Rate for Payer: Aetna Commercial	$241.79
Rate for Payer: Aetna Medicare	$73.50
Rate for Payer: BCN Commercial	$278.87
Rate for Payer: Cash Price	$117.60
Rate for Payer: Cash Price	$117.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$110.25
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$280.97
Rate for Payer: Priority Health Narrow/Tiered Network	$280.97

CHG CT SOFT TISSUE NECK W/O CONTRAST MATERIAL

Professional

Both

$137.00

Service Code	HCPCS 70490
Min. Negotiated Rate	$68.50
Max. Negotiated Rate	$229.29
Rate for Payer: Aetna Commercial	$195.78
Rate for Payer: Aetna Medicare	$68.50
Rate for Payer: BCN Commercial	$227.58
Rate for Payer: Cash Price	$109.60
Rate for Payer: Cash Price	$109.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$102.75
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$229.29
Rate for Payer: Priority Health Narrow/Tiered Network	$229.29

CHG CT SOFT TISSUE NECK W/O & W/CONTRAST MATERIAL

Professional

Both

$171.00

Service Code	HCPCS 70492
Min. Negotiated Rate	$85.50
Max. Negotiated Rate	$337.17
Rate for Payer: Aetna Commercial	$292.92
Rate for Payer: Aetna Medicare	$85.50
Rate for Payer: BCN Commercial	$334.65
Rate for Payer: Cash Price	$136.80
Rate for Payer: Cash Price	$136.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$128.25
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$337.17
Rate for Payer: Priority Health Narrow/Tiered Network	$337.17

CHG CT THORACIC SPINE W/CONTRAST MATERIAL

Professional

Both

$130.00

Service Code	HCPCS 72129
Min. Negotiated Rate	$65.00
Max. Negotiated Rate	$259.89
Rate for Payer: Aetna Commercial	$221.78
Rate for Payer: Aetna Medicare	$65.00
Rate for Payer: BCN Commercial	$257.96
Rate for Payer: Cash Price	$104.00
Rate for Payer: Cash Price	$104.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$97.50
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$259.89
Rate for Payer: Priority Health Narrow/Tiered Network	$259.89

CHG CT THORACIC SPINE W/O CONTRAST MATERIAL

Professional

Both

$106.00

Service Code	HCPCS 72128
Min. Negotiated Rate	$53.00
Max. Negotiated Rate	$198.19
Rate for Payer: Aetna Commercial	$169.24
Rate for Payer: Aetna Medicare	$53.00
Rate for Payer: BCN Commercial	$196.71
Rate for Payer: Cash Price	$84.80
Rate for Payer: Cash Price	$84.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$79.50
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$198.19
Rate for Payer: Priority Health Narrow/Tiered Network	$198.19

CHG CT THORACIC SPINE W/O & W/CONTRAST MATERIAL

Professional

Both

$136.00

Service Code	HCPCS 72130
Min. Negotiated Rate	$68.00
Max. Negotiated Rate	$303.55
Rate for Payer: Aetna Commercial	$259.52
Rate for Payer: Aetna Medicare	$68.00
Rate for Payer: BCN Commercial	$301.28
Rate for Payer: Cash Price	$108.80
Rate for Payer: Cash Price	$108.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$102.00
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$303.55
Rate for Payer: Priority Health Narrow/Tiered Network	$303.55

CHG CT UPPER EXTREMITY W/CONTRAST MATERIAL

Professional

Both

$123.00

Service Code	HCPCS 73201
Min. Negotiated Rate	$61.50
Max. Negotiated Rate	$305.06
Rate for Payer: Aetna Commercial	$265.95
Rate for Payer: Aetna Medicare	$61.50
Rate for Payer: BCN Commercial	$302.77
Rate for Payer: Cash Price	$98.40
Rate for Payer: Cash Price	$98.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$92.25
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$305.06
Rate for Payer: Priority Health Narrow/Tiered Network	$305.06

CHG CT UPPER EXTREMITY W/O CONTRAST MATERIAL

Professional

Both

$106.00

Service Code	HCPCS 73200
Min. Negotiated Rate	$53.00
Max. Negotiated Rate	$245.34
Rate for Payer: Aetna Commercial	$187.00
Rate for Payer: Aetna Medicare	$53.00
Rate for Payer: BCN Commercial	$243.51
Rate for Payer: Cash Price	$84.80
Rate for Payer: Cash Price	$84.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$79.50
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$245.34
Rate for Payer: Priority Health Narrow/Tiered Network	$245.34

CHG CT UPPER EXTREMITY W/O & W/CONTRAST MATERIAL

Professional

Both

$129.00

Service Code	HCPCS 73202
Min. Negotiated Rate	$64.50
Max. Negotiated Rate	$375.80
Rate for Payer: Aetna Commercial	$280.75
Rate for Payer: Aetna Medicare	$64.50
Rate for Payer: BCN Commercial	$372.99
Rate for Payer: Cash Price	$103.20
Rate for Payer: Cash Price	$103.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$96.75
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$375.80
Rate for Payer: Priority Health Narrow/Tiered Network	$375.80

CHG CUL BACT XCPT URINE BLOOD/STOOL AEROBIC ISOL

Professional

Both

$38.00

Service Code	HCPCS 87070
Min. Negotiated Rate	$6.47
Max. Negotiated Rate	$28.50
Rate for Payer: Aetna Commercial	$8.19
Rate for Payer: Aetna Medicare	$19.00
Rate for Payer: BCN Commercial	$6.47
Rate for Payer: Cash Price	$30.40
Rate for Payer: Cash Price	$30.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$28.50
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$9.07
Rate for Payer: Priority Health Narrow/Tiered Network	$9.07

CHG CUL PRSMPTV PTHGNC ORGANISM SCRN W/COLONY ESTIMJ

Professional

Both

$22.00

Service Code	HCPCS 87081
Min. Negotiated Rate	$4.97
Max. Negotiated Rate	$16.50
Rate for Payer: Aetna Commercial	$6.30
Rate for Payer: Aetna Medicare	$11.00
Rate for Payer: BCN Commercial	$4.97
Rate for Payer: Cash Price	$17.60
Rate for Payer: Cash Price	$17.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$16.50
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$6.73
Rate for Payer: Priority Health Narrow/Tiered Network	$6.73

CHG CYSTOGRAPHY MINIMUM 3 VIEWS RS&I

Professional

Both

$107.00

Service Code	HCPCS 74430
Min. Negotiated Rate	$46.64
Max. Negotiated Rate	$80.25
Rate for Payer: Aetna Commercial	$46.64
Rate for Payer: Aetna Medicare	$53.50
Rate for Payer: BCN Commercial	$61.75
Rate for Payer: Cash Price	$85.60
Rate for Payer: Cash Price	$85.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$80.25
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$62.22
Rate for Payer: Priority Health Narrow/Tiered Network	$62.22

CHG CYTP CERVICAL/VAGINAL REQ INTERP PHYSICIAN

Professional

Both

$66.00

Service Code	HCPCS 88141
Min. Negotiated Rate	$15.34
Max. Negotiated Rate	$49.50
Rate for Payer: Aetna Commercial	$19.81
Rate for Payer: Aetna Medicare	$33.00
Rate for Payer: BCBS Complete	$16.11
Rate for Payer: BCN Commercial	$37.35
Rate for Payer: Cash Price	$52.80
Rate for Payer: Cash Price	$52.80
Rate for Payer: Mclaren Medicaid	$15.34
Rate for Payer: Meridian Medicaid	$16.11
Rate for Payer: Opus (Opus Packaging Group) HMA	$49.50
Rate for Payer: Priority Health Choice Medicaid	$15.34
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$37.63
Rate for Payer: Priority Health Narrow/Tiered Network	$37.63
Rate for Payer: UHC Medicaid	$15.34
Rate for Payer: UHCCP Medicaid	$15.34

CHG CYTP CERV/VAG AUTO THIN LAYER PREP MNL SCREEN

Professional

Both

$48.00

Service Code	HCPCS 88142
Min. Negotiated Rate	$15.20
Max. Negotiated Rate	$36.00
Rate for Payer: Aetna Commercial	$19.25
Rate for Payer: Aetna Medicare	$24.00
Rate for Payer: BCN Commercial	$15.20
Rate for Payer: Cash Price	$38.40
Rate for Payer: Cash Price	$38.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$36.00
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$31.61
Rate for Payer: Priority Health Narrow/Tiered Network	$31.61

CHG DEXA,BONE DENSITY,VERTEB FRACT

Professional

Both

$20.00

Service Code	HCPCS 77082
Min. Negotiated Rate	$8.00
Max. Negotiated Rate	$15.00
Rate for Payer: Aetna Medicare	$10.00
Rate for Payer: BCBS Complete	$8.00
Rate for Payer: Cash Price	$16.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$15.00

CHG DIAGNOSTIC COMPUTED TOMOGRAPHY THORAX C-/C+

Professional

Both

$133.00

Service Code	HCPCS 71270
Min. Negotiated Rate	$66.50
Max. Negotiated Rate	$299.54
Rate for Payer: Aetna Commercial	$258.23
Rate for Payer: Aetna Medicare	$66.50
Rate for Payer: BCN Commercial	$297.29
Rate for Payer: Cash Price	$106.40
Rate for Payer: Cash Price	$106.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$99.75
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$299.54
Rate for Payer: Priority Health Narrow/Tiered Network	$299.54

CHG DIAGNOSTIC COMPUTED TOMOGRAPHY THORAX W/CONTRAST

Professional

Both

$124.00

Service Code	HCPCS 71260
Min. Negotiated Rate	$62.00
Max. Negotiated Rate	$254.88
Rate for Payer: Aetna Commercial	$218.31
Rate for Payer: Aetna Medicare	$62.00
Rate for Payer: BCN Commercial	$252.97
Rate for Payer: Cash Price	$99.20
Rate for Payer: Cash Price	$99.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$93.00
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$254.88
Rate for Payer: Priority Health Narrow/Tiered Network	$254.88

CHG DIAGNOSTIC COMPUTED TOMOGRAPHY THORAX W/O CNTRST

Professional

Both

$115.00

Service Code	HCPCS 71250
Min. Negotiated Rate	$57.50
Max. Negotiated Rate	$203.20
Rate for Payer: Aetna Commercial	$173.19
Rate for Payer: Aetna Medicare	$57.50
Rate for Payer: BCN Commercial	$201.68
Rate for Payer: Cash Price	$92.00
Rate for Payer: Cash Price	$92.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$86.25
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$203.20
Rate for Payer: Priority Health Narrow/Tiered Network	$203.20

CHG DIGITAL BREAST TOMOSYNTHESIS UNILATERAL

Professional

Both

$68.00

Service Code	HCPCS 77061
Min. Negotiated Rate	$27.20
Max. Negotiated Rate	$189.16
Rate for Payer: Aetna Commercial	$146.59
Rate for Payer: Aetna Medicare	$34.00
Rate for Payer: BCBS Complete	$27.20
Rate for Payer: BCN Commercial	$85.23
Rate for Payer: Cash Price	$54.40
Rate for Payer: Cash Price	$54.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$51.00
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$189.16
Rate for Payer: Priority Health Narrow/Tiered Network	$189.16

CHG DISKOGRAPY LUMBAR RS&I

Professional

Both

$108.00

Service Code	HCPCS 72295
Min. Negotiated Rate	$54.00
Max. Negotiated Rate	$166.57
Rate for Payer: Aetna Commercial	$128.76
Rate for Payer: Aetna Medicare	$54.00
Rate for Payer: BCN Commercial	$165.33
Rate for Payer: Cash Price	$86.40
Rate for Payer: Cash Price	$86.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$81.00
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$166.57
Rate for Payer: Priority Health Narrow/Tiered Network	$166.57

CHG DOPPLER ECHO FETAL PULS SPECTRAL F/U/REPEAT

Professional

Both

$149.00

Service Code	HCPCS 76828
Min. Negotiated Rate	$59.77
Max. Negotiated Rate	$111.75
Rate for Payer: Aetna Commercial	$59.77
Rate for Payer: Aetna Medicare	$74.50
Rate for Payer: BCN Commercial	$71.71
Rate for Payer: Cash Price	$119.20
Rate for Payer: Cash Price	$119.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$111.75
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$72.25
Rate for Payer: Priority Health Narrow/Tiered Network	$72.25

CHG DOPPLER ECHO FETAL SPECTRAL DISPLAY COMPLETE

Professional

Both

$249.00

Service Code	HCPCS 76827
Min. Negotiated Rate	$84.26
Max. Negotiated Rate	$186.75
Rate for Payer: Aetna Commercial	$84.26
Rate for Payer: Aetna Medicare	$124.50
Rate for Payer: BCN Commercial	$102.59
Rate for Payer: Cash Price	$199.20
Rate for Payer: Cash Price	$199.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$186.75
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$103.35
Rate for Payer: Priority Health Narrow/Tiered Network	$103.35

CHG DOPPLER VELOCIMETRY FETAL MIDDLE CEREBRAL ART

Professional

Both

$148.00

Service Code	HCPCS 76821
Min. Negotiated Rate	$74.00
Max. Negotiated Rate	$131.95
Rate for Payer: Aetna Commercial	$104.92
Rate for Payer: Aetna Medicare	$74.00
Rate for Payer: BCN Commercial	$130.97
Rate for Payer: Cash Price	$118.40
Rate for Payer: Cash Price	$118.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$111.00
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$131.95
Rate for Payer: Priority Health Narrow/Tiered Network	$131.95

Know your out-of-pocket cost for care.

All Charges