Bronson Lakeview Hospital

All Charges

Charge

Type

Setting

Price

CHG MRI BRAIN BRAIN STEM W/O CONTRAST MATERIAL

Professional

Both

$335.00

Service Code	HCPCS 70551
Min. Negotiated Rate	$167.50
Max. Negotiated Rate	$318.81
Rate for Payer: Aetna Commercial	$318.81
Rate for Payer: Aetna Medicare	$167.50
Rate for Payer: BCN Commercial	$297.79
Rate for Payer: Cash Price	$268.00
Rate for Payer: Cash Price	$268.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$251.25
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$300.03
Rate for Payer: Priority Health Narrow/Tiered Network	$300.03

CHG MRI BRAIN BRAIN STEM W/O W/CONTRAST MATERIAL

Professional

Both

$358.00

Service Code	HCPCS 70553
Min. Negotiated Rate	$179.00
Max. Negotiated Rate	$523.42
Rate for Payer: Aetna Commercial	$523.42
Rate for Payer: Aetna Medicare	$179.00
Rate for Payer: BCN Commercial	$483.54
Rate for Payer: Cash Price	$286.40
Rate for Payer: Cash Price	$286.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$268.50
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$487.17
Rate for Payer: Priority Health Narrow/Tiered Network	$487.17

CHG MRI GUIDANCE NEEDLE PLACEMENT RS&I

Professional

Both

$168.00

Service Code	HCPCS 77021
Min. Negotiated Rate	$84.00
Max. Negotiated Rate	$673.13
Rate for Payer: Aetna Commercial	$673.13
Rate for Payer: Aetna Medicare	$84.00
Rate for Payer: BCN Commercial	$620.98
Rate for Payer: Cash Price	$134.40
Rate for Payer: Cash Price	$134.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$126.00
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$625.66
Rate for Payer: Priority Health Narrow/Tiered Network	$625.66

CHG MRI LOWER EXTREM OTH/THN JT W/O CONTR MATRL

Professional

Both

$135.00

Service Code	HCPCS 73718
Min. Negotiated Rate	$67.50
Max. Negotiated Rate	$368.90
Rate for Payer: Aetna Commercial	$368.90
Rate for Payer: Aetna Medicare	$67.50
Rate for Payer: BCN Commercial	$337.13
Rate for Payer: Cash Price	$108.00
Rate for Payer: Cash Price	$108.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$101.25
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$339.68
Rate for Payer: Priority Health Narrow/Tiered Network	$339.68

CHG MRI LOWER EXTREM OTH/THN JT W/O & W/CONTR MATR

Professional

Both

$216.00

Service Code	HCPCS 73720
Min. Negotiated Rate	$108.00
Max. Negotiated Rate	$560.16
Rate for Payer: Aetna Commercial	$560.16
Rate for Payer: Aetna Medicare	$108.00
Rate for Payer: BCN Commercial	$510.44
Rate for Payer: Cash Price	$172.80
Rate for Payer: Cash Price	$172.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$162.00
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$514.27
Rate for Payer: Priority Health Narrow/Tiered Network	$514.27

CHG MRI ORBIT FACE &/NECK W/O CONTRAST

Professional

Both

$134.00

Service Code	HCPCS 70540
Min. Negotiated Rate	$67.00
Max. Negotiated Rate	$373.33
Rate for Payer: Aetna Commercial	$373.33
Rate for Payer: Aetna Medicare	$67.00
Rate for Payer: BCN Commercial	$342.12
Rate for Payer: Cash Price	$107.20
Rate for Payer: Cash Price	$107.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$100.50
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$344.69
Rate for Payer: Priority Health Narrow/Tiered Network	$344.69

CHG MRI ORBIT FACE & NECK W/O & W/CONTRAST MATRL

Professional

Both

$216.00

Service Code	HCPCS 70543
Min. Negotiated Rate	$108.00
Max. Negotiated Rate	$560.16
Rate for Payer: Aetna Commercial	$560.16
Rate for Payer: Aetna Medicare	$108.00
Rate for Payer: BCN Commercial	$513.42
Rate for Payer: Cash Price	$172.80
Rate for Payer: Cash Price	$172.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$162.00
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$517.28
Rate for Payer: Priority Health Narrow/Tiered Network	$517.28

CHG MRI PELVIS W/O CONTRAST MATERIAL

Professional

Both

$146.00

Service Code	HCPCS 72195
Min. Negotiated Rate	$73.00
Max. Negotiated Rate	$379.81
Rate for Payer: Aetna Commercial	$379.81
Rate for Payer: Aetna Medicare	$73.00
Rate for Payer: BCN Commercial	$345.59
Rate for Payer: Cash Price	$116.80
Rate for Payer: Cash Price	$116.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$109.50
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$348.19
Rate for Payer: Priority Health Narrow/Tiered Network	$348.19

CHG MRI PELVIS W/O & W/CONTRAST MATERIAL

Professional

Both

$220.00

Service Code	HCPCS 72197
Min. Negotiated Rate	$110.00
Max. Negotiated Rate	$560.40
Rate for Payer: Aetna Commercial	$560.40
Rate for Payer: Aetna Medicare	$110.00
Rate for Payer: BCN Commercial	$509.93
Rate for Payer: Cash Price	$176.00
Rate for Payer: Cash Price	$176.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$165.00
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$513.78
Rate for Payer: Priority Health Narrow/Tiered Network	$513.78

CHG MRI SPINAL CANAL CERVICAL W/O CONTRAST MATRL

Professional

Both

$311.00

Service Code	HCPCS 72141
Min. Negotiated Rate	$155.50
Max. Negotiated Rate	$311.87
Rate for Payer: Aetna Commercial	$311.87
Rate for Payer: Aetna Medicare	$155.50
Rate for Payer: BCN Commercial	$288.83
Rate for Payer: Cash Price	$248.80
Rate for Payer: Cash Price	$248.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$233.25
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$291.00
Rate for Payer: Priority Health Narrow/Tiered Network	$291.00

CHG MRI SPINAL CANAL CERVICAL W/O & W/CONTR MATRL

Professional

Both

$323.00

Service Code	HCPCS 72156
Min. Negotiated Rate	$161.50
Max. Negotiated Rate	$528.35
Rate for Payer: Aetna Commercial	$528.35
Rate for Payer: Aetna Medicare	$161.50
Rate for Payer: BCN Commercial	$485.03
Rate for Payer: Cash Price	$258.40
Rate for Payer: Cash Price	$258.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$242.25
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$488.68
Rate for Payer: Priority Health Narrow/Tiered Network	$488.68

CHG MRI SPINAL CANAL LUMBAR W/CONTRAST MATERIAL

Professional

Both

$337.00

Service Code	HCPCS 72149
Min. Negotiated Rate	$168.50
Max. Negotiated Rate	$446.00
Rate for Payer: Aetna Commercial	$446.00
Rate for Payer: Aetna Medicare	$168.50
Rate for Payer: BCN Commercial	$409.84
Rate for Payer: Cash Price	$269.60
Rate for Payer: Cash Price	$269.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$252.75
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$412.92
Rate for Payer: Priority Health Narrow/Tiered Network	$412.92

CHG MRI SPINAL CANAL LUMBAR W/O CONTRAST MATERIAL

Professional

Both

$254.00

Service Code	HCPCS 72148
Min. Negotiated Rate	$127.00
Max. Negotiated Rate	$312.37
Rate for Payer: Aetna Commercial	$312.37
Rate for Payer: Aetna Medicare	$127.00
Rate for Payer: BCN Commercial	$289.82
Rate for Payer: Cash Price	$203.20
Rate for Payer: Cash Price	$203.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$190.50
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$292.01
Rate for Payer: Priority Health Narrow/Tiered Network	$292.01

CHG MRI SPINAL CANAL LUMBAR W/O & W/CONTR MATRL

Professional

Both

$308.00

Service Code	HCPCS 72158
Min. Negotiated Rate	$154.00
Max. Negotiated Rate	$527.37
Rate for Payer: Aetna Commercial	$527.37
Rate for Payer: Aetna Medicare	$154.00
Rate for Payer: BCN Commercial	$484.04
Rate for Payer: Cash Price	$246.40
Rate for Payer: Cash Price	$246.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$231.00
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$487.69
Rate for Payer: Priority Health Narrow/Tiered Network	$487.69

CHG MRI SPINAL CANAL THORACIC W/O CONTRAST MATRL

Professional

Both

$280.00

Service Code	HCPCS 72146
Min. Negotiated Rate	$140.00
Max. Negotiated Rate	$311.87
Rate for Payer: Aetna Commercial	$311.87
Rate for Payer: Aetna Medicare	$140.00
Rate for Payer: BCN Commercial	$289.33
Rate for Payer: Cash Price	$224.00
Rate for Payer: Cash Price	$224.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$210.00
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$291.50
Rate for Payer: Priority Health Narrow/Tiered Network	$291.50

CHG MRI SPINAL CANAL THORACIC W/O & W/CONTR MATRL

Professional

Both

$340.00

Service Code	HCPCS 72157
Min. Negotiated Rate	$170.00
Max. Negotiated Rate	$529.34
Rate for Payer: Aetna Commercial	$529.34
Rate for Payer: Aetna Medicare	$170.00
Rate for Payer: BCN Commercial	$486.03
Rate for Payer: Cash Price	$272.00
Rate for Payer: Cash Price	$272.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$255.00
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$489.69
Rate for Payer: Priority Health Narrow/Tiered Network	$489.69

CHG MRI UPPER EXTREMITY OTH THAN JT W/O CONTR MATRL

Professional

Both

$136.00

Service Code	HCPCS 73218
Min. Negotiated Rate	$68.00
Max. Negotiated Rate	$459.58
Rate for Payer: Aetna Commercial	$425.56
Rate for Payer: Aetna Medicare	$68.00
Rate for Payer: BCN Commercial	$456.15
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	$459.58
Rate for Payer: Priority Health Narrow/Tiered Network	$459.58

CHG MYELOGRAPY LUMBOSACRAL RS&I

Professional

Both

$168.00

Service Code	HCPCS 72265
Min. Negotiated Rate	$84.00
Max. Negotiated Rate	$162.56
Rate for Payer: Aetna Commercial	$124.16
Rate for Payer: Aetna Medicare	$84.00
Rate for Payer: BCN Commercial	$161.34
Rate for Payer: Cash Price	$134.40
Rate for Payer: Cash Price	$134.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$126.00
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$162.56
Rate for Payer: Priority Health Narrow/Tiered Network	$162.56

CHG MYOCARDIAL PERFUSION PLANAR 1 STUDY REST/STRESS

Professional

Both

$126.00

Service Code	HCPCS 78453
Min. Negotiated Rate	$63.00
Max. Negotiated Rate	$396.87
Rate for Payer: Aetna Commercial	$339.63
Rate for Payer: Aetna Medicare	$63.00
Rate for Payer: BCN Commercial	$393.91
Rate for Payer: Cash Price	$100.80
Rate for Payer: Cash Price	$100.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$94.50
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$396.87
Rate for Payer: Priority Health Narrow/Tiered Network	$396.87

CHG MYOCARDIAL PERFUSION PLANAR MULTIPLE STUDIES

Professional

Both

$163.00

Service Code	HCPCS 78454
Min. Negotiated Rate	$81.50
Max. Negotiated Rate	$587.53
Rate for Payer: Aetna Commercial	$490.87
Rate for Payer: Aetna Medicare	$81.50
Rate for Payer: BCN Commercial	$583.13
Rate for Payer: Cash Price	$130.40
Rate for Payer: Cash Price	$130.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$122.25
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$587.53
Rate for Payer: Priority Health Narrow/Tiered Network	$587.53

CHG MYOCARDIAL SPECT MULTIPLE STUDIES

Professional

Both

$198.00

Service Code	HCPCS 78452
Min. Negotiated Rate	$99.00
Max. Negotiated Rate	$634.19
Rate for Payer: Aetna Commercial	$538.09
Rate for Payer: Aetna Commercial	$538.09
Rate for Payer: Aetna Medicare	$99.00
Rate for Payer: Aetna Medicare	$471.50
Rate for Payer: BCN Commercial	$629.45
Rate for Payer: BCN Commercial	$629.45
Rate for Payer: Cash Price	$754.40
Rate for Payer: Cash Price	$158.40
Rate for Payer: Cash Price	$754.40
Rate for Payer: Cash Price	$158.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$148.50
Rate for Payer: Opus (Opus Packaging Group) HMA	$707.25
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$634.19
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$634.19
Rate for Payer: Priority Health Narrow/Tiered Network	$634.19
Rate for Payer: Priority Health Narrow/Tiered Network	$634.19

CHG MYOCARDIAL SPECT SINGLE STUDY AT REST OR STRESS

Professional

Both

$173.00

Service Code	HCPCS 78451
Min. Negotiated Rate	$86.50
Max. Negotiated Rate	$460.59
Rate for Payer: Aetna Commercial	$387.26
Rate for Payer: Aetna Medicare	$86.50
Rate for Payer: BCN Commercial	$457.15
Rate for Payer: Cash Price	$138.40
Rate for Payer: Cash Price	$138.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$129.75
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$460.59
Rate for Payer: Priority Health Narrow/Tiered Network	$460.59

CHG MYOCRD IMG PET PRFUJ MLT STD RST&STRS CNCRNT CT

Professional

Both

$255.00

Service Code	HCPCS 78431
Min. Negotiated Rate	$102.00
Max. Negotiated Rate	$2,093.10
Rate for Payer: Aetna Commercial	$2,093.10
Rate for Payer: Aetna Medicare	$127.50
Rate for Payer: BCBS Complete	$102.00
Rate for Payer: BCN Commercial	$128.98
Rate for Payer: Cash Price	$204.00
Rate for Payer: Cash Price	$204.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$191.25
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$928.20
Rate for Payer: Priority Health Narrow/Tiered Network	$928.20

CHG MYOCRD IMG PET PRFUJ SINGLE STUDY REST/STRESS

Professional

Both

$735.00

Service Code	HCPCS 78491
Min. Negotiated Rate	$106.08
Max. Negotiated Rate	$1,378.75
Rate for Payer: Aetna Commercial	$1,378.75
Rate for Payer: Aetna Medicare	$367.50
Rate for Payer: BCN Commercial	$106.08
Rate for Payer: Cash Price	$588.00
Rate for Payer: Cash Price	$588.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$551.25
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$667.80
Rate for Payer: Priority Health Narrow/Tiered Network	$667.80

CHG NTSTY MODUL RADTHX PLN DOSE-VOL HISTOS

Professional

Both

$3,163.00

Service Code	HCPCS 77301
Min. Negotiated Rate	$1,581.50
Max. Negotiated Rate	$2,817.92
Rate for Payer: Aetna Commercial	$2,146.90
Rate for Payer: Aetna Commercial	$2,146.90
Rate for Payer: Aetna Commercial	$2,146.90
Rate for Payer: Aetna Medicare	$902.50
Rate for Payer: Aetna Medicare	$1,967.50
Rate for Payer: Aetna Medicare	$1,581.50
Rate for Payer: BCN Commercial	$2,817.92
Rate for Payer: BCN Commercial	$2,817.92
Rate for Payer: BCN Commercial	$2,817.92
Rate for Payer: Cash Price	$2,530.40
Rate for Payer: Cash Price	$1,444.00
Rate for Payer: Cash Price	$3,148.00
Rate for Payer: Cash Price	$1,444.00
Rate for Payer: Cash Price	$2,530.40
Rate for Payer: Cash Price	$3,148.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$2,951.25
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,353.75
Rate for Payer: Opus (Opus Packaging Group) HMA	$2,372.25
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$2,788.62
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$2,788.62
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$2,788.62
Rate for Payer: Priority Health Narrow/Tiered Network	$2,788.62
Rate for Payer: Priority Health Narrow/Tiered Network	$2,788.62
Rate for Payer: Priority Health Narrow/Tiered Network	$2,788.62

Know your out-of-pocket cost for care.

All Charges