Bronson Lakeview Hospital

All Charges

Charge

Type

Setting

Price

CHG RADIOLOGIC EXAM SMALL INT SINGLE CONTRAST STUDY

Professional

Both

$243.00

Service Code	HCPCS 74250
Min. Negotiated Rate	$121.50
Max. Negotiated Rate	$182.25
Rate for Payer: Aetna Commercial	$143.54
Rate for Payer: Aetna Medicare	$121.50
Rate for Payer: BCN Commercial	$179.28
Rate for Payer: Cash Price	$194.40
Rate for Payer: Cash Price	$194.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$182.25
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$180.63
Rate for Payer: Priority Health Narrow/Tiered Network	$180.63

CHG RADN RX DELIVERY COMPLX 11-19 MEV

Professional

Both

$489.00

Service Code	HCPCS 77414
Min. Negotiated Rate	$195.60
Max. Negotiated Rate	$366.75
Rate for Payer: Aetna Medicare	$244.50
Rate for Payer: BCBS Complete	$195.60
Rate for Payer: Cash Price	$391.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$366.75

CHG RADN RX DELIVERY COMPLX 6-10 MEV

Professional

Both

$435.00

Service Code	HCPCS 77413
Min. Negotiated Rate	$174.00
Max. Negotiated Rate	$326.25
Rate for Payer: Aetna Medicare	$217.50
Rate for Payer: BCBS Complete	$174.00
Rate for Payer: Cash Price	$348.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$326.25

CHG RADN RX DELIVERY SIMPLE 11-19 MEV

Professional

Both

$269.00

Service Code	HCPCS 77404
Min. Negotiated Rate	$107.60
Max. Negotiated Rate	$201.75
Rate for Payer: Aetna Medicare	$134.50
Rate for Payer: BCBS Complete	$107.60
Rate for Payer: Cash Price	$215.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$201.75

CHG RADN RX DELIVERY SIMPLE 6-10 MEV

Professional

Both

$241.00

Service Code	HCPCS 77403
Min. Negotiated Rate	$96.40
Max. Negotiated Rate	$180.75
Rate for Payer: Aetna Medicare	$120.50
Rate for Payer: BCBS Complete	$96.40
Rate for Payer: Cash Price	$192.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$180.75

CHG REMOTE AFTLD RADIONUC BRACHYTHERAPY,1 CHANNEL

Professional

Both

$318.00

Service Code	HCPCS 77785
Min. Negotiated Rate	$127.20
Max. Negotiated Rate	$238.50
Rate for Payer: Aetna Medicare	$159.00
Rate for Payer: Aetna Medicare	$235.00
Rate for Payer: BCBS Complete	$188.00
Rate for Payer: BCBS Complete	$127.20
Rate for Payer: Cash Price	$254.40
Rate for Payer: Cash Price	$376.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$238.50
Rate for Payer: Opus (Opus Packaging Group) HMA	$352.50

CHG REMOTE AFTLD RADIONUC BRACHYTHERAPY,2-12 CHANNEL

Professional

Both

$702.00

Service Code	HCPCS 77786
Min. Negotiated Rate	$280.80
Max. Negotiated Rate	$526.50
Rate for Payer: Aetna Medicare	$351.00
Rate for Payer: Aetna Medicare	$517.50
Rate for Payer: BCBS Complete	$280.80
Rate for Payer: BCBS Complete	$414.00
Rate for Payer: Cash Price	$828.00
Rate for Payer: Cash Price	$561.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$526.50
Rate for Payer: Opus (Opus Packaging Group) HMA	$776.25

CHG REPAIR,ILIAC ANRYSM/PSEUDO/AV MALF/TRAUMA W/ ENDOPROSTHESIS

Professional

Both

$227.00

Service Code	HCPCS 75954
Min. Negotiated Rate	$90.80
Max. Negotiated Rate	$170.25
Rate for Payer: Aetna Medicare	$113.50
Rate for Payer: BCBS Complete	$90.80
Rate for Payer: Cash Price	$181.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$170.25

CHG RESPIRATORY MOTION MANAGEMENT SIMULATION

Professional

Both

$851.00

Service Code	HCPCS 77293
Min. Negotiated Rate	$425.50
Max. Negotiated Rate	$638.25
Rate for Payer: Aetna Commercial	$505.24
Rate for Payer: Aetna Commercial	$505.24
Rate for Payer: Aetna Medicare	$318.50
Rate for Payer: Aetna Medicare	$425.50
Rate for Payer: BCN Commercial	$601.56
Rate for Payer: BCN Commercial	$601.56
Rate for Payer: Cash Price	$509.60
Rate for Payer: Cash Price	$509.60
Rate for Payer: Cash Price	$680.80
Rate for Payer: Cash Price	$680.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$638.25
Rate for Payer: Opus (Opus Packaging Group) HMA	$477.75
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$606.10
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$606.10
Rate for Payer: Priority Health Narrow/Tiered Network	$606.10
Rate for Payer: Priority Health Narrow/Tiered Network	$606.10

CHG RP LOCLZJ TUM SPECT 1 AREA/ACQUISJ 1 DAY IMG

Professional

Both

$720.00

Service Code	HCPCS 78803
Min. Negotiated Rate	$360.00
Max. Negotiated Rate	$540.00
Rate for Payer: Aetna Commercial	$438.41
Rate for Payer: Aetna Commercial	$438.41
Rate for Payer: Aetna Commercial	$438.41
Rate for Payer: Aetna Medicare	$45.00
Rate for Payer: Aetna Medicare	$315.00
Rate for Payer: Aetna Medicare	$360.00
Rate for Payer: BCN Commercial	$504.96
Rate for Payer: BCN Commercial	$504.96
Rate for Payer: BCN Commercial	$504.96
Rate for Payer: Cash Price	$72.00
Rate for Payer: Cash Price	$504.00
Rate for Payer: Cash Price	$504.00
Rate for Payer: Cash Price	$576.00
Rate for Payer: Cash Price	$576.00
Rate for Payer: Cash Price	$72.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$540.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$472.50
Rate for Payer: Opus (Opus Packaging Group) HMA	$67.50
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$508.75
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$508.75
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$508.75
Rate for Payer: Priority Health Narrow/Tiered Network	$508.75
Rate for Payer: Priority Health Narrow/Tiered Network	$508.75
Rate for Payer: Priority Health Narrow/Tiered Network	$508.75

CHG RP THERAPY INTRAVENOUS ADMINISTRATION

Professional

Both

$302.00

Service Code	HCPCS 79101
Min. Negotiated Rate	$151.00
Max. Negotiated Rate	$226.50
Rate for Payer: Aetna Commercial	$172.32
Rate for Payer: Aetna Commercial	$172.32
Rate for Payer: Aetna Medicare	$151.00
Rate for Payer: Aetna Medicare	$271.50
Rate for Payer: BCN Commercial	$217.12
Rate for Payer: BCN Commercial	$217.12
Rate for Payer: Cash Price	$434.40
Rate for Payer: Cash Price	$241.60
Rate for Payer: Cash Price	$434.40
Rate for Payer: Cash Price	$241.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$226.50
Rate for Payer: Opus (Opus Packaging Group) HMA	$407.25
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$218.75
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$218.75
Rate for Payer: Priority Health Narrow/Tiered Network	$218.75
Rate for Payer: Priority Health Narrow/Tiered Network	$218.75

CHG RP THERAPY ORAL ADMINISTRATION

Professional

Both

$160.00

Service Code	HCPCS 79005
Min. Negotiated Rate	$80.00
Max. Negotiated Rate	$202.70
Rate for Payer: Aetna Commercial	$158.75
Rate for Payer: Aetna Commercial	$158.75
Rate for Payer: Aetna Medicare	$80.00
Rate for Payer: Aetna Medicare	$134.00
Rate for Payer: BCN Commercial	$201.18
Rate for Payer: BCN Commercial	$201.18
Rate for Payer: Cash Price	$214.40
Rate for Payer: Cash Price	$128.00
Rate for Payer: Cash Price	$214.40
Rate for Payer: Cash Price	$128.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$120.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$201.00
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$202.70
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$202.70
Rate for Payer: Priority Health Narrow/Tiered Network	$202.70
Rate for Payer: Priority Health Narrow/Tiered Network	$202.70

CHG SALINE INFUS SONOHYSTEROGRAPHY W/COLOR DOPPLER

Professional

Both

$247.00

Service Code	HCPCS 76831
Min. Negotiated Rate	$123.50
Max. Negotiated Rate	$185.25
Rate for Payer: Aetna Commercial	$138.24
Rate for Payer: Aetna Medicare	$123.50
Rate for Payer: BCN Commercial	$170.31
Rate for Payer: Cash Price	$197.60
Rate for Payer: Cash Price	$197.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$185.25
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$171.60
Rate for Payer: Priority Health Narrow/Tiered Network	$171.60

CHG SCREENING DIGITAL BREAST TOMOSYNTHESIS BI

Professional

Both

$64.00

Service Code	HCPCS 77063
Min. Negotiated Rate	$32.00
Max. Negotiated Rate	$78.77
Rate for Payer: Aetna Commercial	$63.00
Rate for Payer: Aetna Medicare	$32.00
Rate for Payer: BCN Commercial	$78.18
Rate for Payer: Cash Price	$51.20
Rate for Payer: Cash Price	$51.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$48.00
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$78.77
Rate for Payer: Priority Health Narrow/Tiered Network	$78.77

CHG SCREENING MAMMOGRAPHY BI 2-VIEW BREAST INC CAD

Professional

Both

$81.00

Service Code	HCPCS 77067
Min. Negotiated Rate	$40.50
Max. Negotiated Rate	$193.16
Rate for Payer: Aetna Commercial	$149.83
Rate for Payer: Aetna Medicare	$40.50
Rate for Payer: BCN Commercial	$191.72
Rate for Payer: Cash Price	$64.80
Rate for Payer: Cash Price	$64.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$60.75
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$193.16
Rate for Payer: Priority Health Narrow/Tiered Network	$193.16

CHG SEDIMENTATION RATE RBC NON-AUTOMATED

Professional

Both

$15.00

Service Code	HCPCS 85651
Min. Negotiated Rate	$3.20
Max. Negotiated Rate	$11.25
Rate for Payer: Aetna Commercial	$4.06
Rate for Payer: Aetna Medicare	$7.50
Rate for Payer: BCN Commercial	$3.20
Rate for Payer: Cash Price	$12.00
Rate for Payer: Cash Price	$12.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$11.25
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$4.38
Rate for Payer: Priority Health Narrow/Tiered Network	$4.38

CHG SEMEN ALYS MOTILITY&CNT X W/HUHNER TST

Professional

Both

$22.00

Service Code	HCPCS 89310
Min. Negotiated Rate	$6.46
Max. Negotiated Rate	$16.50
Rate for Payer: Aetna Commercial	$8.18
Rate for Payer: Aetna Medicare	$11.00
Rate for Payer: BCN Commercial	$6.46
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	$13.54
Rate for Payer: Priority Health Narrow/Tiered Network	$13.54

CHG SEMEN ALYS PRESENCE&/MOTILITY SPRM HUHNER

Professional

Both

$48.00

Service Code	HCPCS 89300
Min. Negotiated Rate	$7.38
Max. Negotiated Rate	$36.00
Rate for Payer: Aetna Commercial	$9.35
Rate for Payer: Aetna Medicare	$24.00
Rate for Payer: BCN Commercial	$7.38
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	$15.05
Rate for Payer: Priority Health Narrow/Tiered Network	$15.05

CHG SEMEN ANALYSIS SPERM PRESENCE&/MOTILITY SPRM

Professional

Both

$30.00

Service Code	HCPCS 89321
Min. Negotiated Rate	$9.04
Max. Negotiated Rate	$22.50
Rate for Payer: Aetna Commercial	$11.45
Rate for Payer: Aetna Medicare	$15.00
Rate for Payer: BCBS Complete	$12.00
Rate for Payer: BCN Commercial	$9.04
Rate for Payer: Cash Price	$24.00
Rate for Payer: Cash Price	$24.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$22.50
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$18.57
Rate for Payer: Priority Health Narrow/Tiered Network	$18.57

CHG SHUNTOGRAM INDWELLING NONVASCULAR SHUNT RS&I

Professional

Both

$198.00

Service Code	HCPCS 75809
Min. Negotiated Rate	$99.00
Max. Negotiated Rate	$148.50
Rate for Payer: Aetna Commercial	$101.45
Rate for Payer: Aetna Medicare	$99.00
Rate for Payer: BCN Commercial	$121.01
Rate for Payer: Cash Price	$158.40
Rate for Payer: Cash Price	$158.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$148.50
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$121.92
Rate for Payer: Priority Health Narrow/Tiered Network	$121.92

CHG SKIN TEST TUBERCULOSIS INTRADERMAL

Professional

Both

$16.00

Service Code	HCPCS 86580
Min. Negotiated Rate	$8.00
Max. Negotiated Rate	$14.94
Rate for Payer: Aetna Commercial	$8.78
Rate for Payer: Aetna Medicare	$8.00
Rate for Payer: BCN Commercial	$14.94
Rate for Payer: Cash Price	$12.80
Rate for Payer: Cash Price	$12.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$12.00
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$10.08
Rate for Payer: Priority Health Narrow/Tiered Network	$10.08

CHG SMR PRIM SRC CPLX SPEC STAIN OVA&PARASITS

Professional

Both

$50.00

Service Code	HCPCS 87209
Min. Negotiated Rate	$13.49
Max. Negotiated Rate	$37.50
Rate for Payer: Aetna Commercial	$17.08
Rate for Payer: Aetna Medicare	$25.00
Rate for Payer: BCN Commercial	$13.49
Rate for Payer: Cash Price	$40.00
Rate for Payer: Cash Price	$40.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$37.50
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$18.82
Rate for Payer: Priority Health Narrow/Tiered Network	$18.82

CHG SMR PRIM SRC WET MOUNT NFCT AGT

Professional

Both

$19.00

Service Code	HCPCS 87210
Min. Negotiated Rate	$5.53
Max. Negotiated Rate	$14.25
Rate for Payer: Aetna Commercial	$5.53
Rate for Payer: Aetna Medicare	$9.50
Rate for Payer: BCN Commercial	$5.82
Rate for Payer: Cash Price	$15.20
Rate for Payer: Cash Price	$15.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$14.25
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$6.05
Rate for Payer: Priority Health Narrow/Tiered Network	$6.05

CHG SONO GUIDE PERICARD TAP

Professional

Both

$125.00

Service Code	HCPCS 76930
Min. Negotiated Rate	$50.00
Max. Negotiated Rate	$93.75
Rate for Payer: Aetna Medicare	$62.50
Rate for Payer: BCBS Complete	$50.00
Rate for Payer: Cash Price	$100.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$93.75

CHG SONO GUIDE RAD THERAPY FIELDS

Professional

Both

$77.00

Service Code	HCPCS 76950
Min. Negotiated Rate	$30.80
Max. Negotiated Rate	$57.75
Rate for Payer: Aetna Medicare	$38.50
Rate for Payer: Aetna Medicare	$71.00
Rate for Payer: BCBS Complete	$56.80
Rate for Payer: BCBS Complete	$30.80
Rate for Payer: Cash Price	$113.60
Rate for Payer: Cash Price	$61.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$57.75
Rate for Payer: Opus (Opus Packaging Group) HMA	$106.50

Know your out-of-pocket cost for care.

All Charges