Bronson Lakeview Hospital

All Charges

Charge

Type

Setting

Price

CHG US RETROPERITONEAL REAL TIME W/IMAGE LIMITED

Professional

Both

$200.00

Service Code	HCPCS 76775
Min. Negotiated Rate	$67.91
Max. Negotiated Rate	$150.00
Rate for Payer: Aetna Commercial	$67.91
Rate for Payer: Aetna Medicare	$100.00
Rate for Payer: BCN Commercial	$90.63
Rate for Payer: Cash Price	$160.00
Rate for Payer: Cash Price	$160.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$150.00
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$91.31
Rate for Payer: Priority Health Narrow/Tiered Network	$91.31

CHG US SCROTUM & CONTENTS

Professional

Both

$64.00

Service Code	HCPCS 76870
Min. Negotiated Rate	$32.00
Max. Negotiated Rate	$150.02
Rate for Payer: Aetna Commercial	$120.01
Rate for Payer: Aetna Medicare	$32.00
Rate for Payer: BCN Commercial	$148.90
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	$150.02
Rate for Payer: Priority Health Narrow/Tiered Network	$150.02

CHG US SOFT TISSUE HEAD & NECK REAL TIME IMGE DOCM

Professional

Both

$105.00

Service Code	HCPCS 76536
Min. Negotiated Rate	$52.50
Max. Negotiated Rate	$164.57
Rate for Payer: Aetna Commercial	$132.69
Rate for Payer: Aetna Commercial	$132.69
Rate for Payer: Aetna Medicare	$52.50
Rate for Payer: Aetna Medicare	$117.00
Rate for Payer: BCN Commercial	$163.34
Rate for Payer: BCN Commercial	$163.34
Rate for Payer: Cash Price	$187.20
Rate for Payer: Cash Price	$84.00
Rate for Payer: Cash Price	$187.20
Rate for Payer: Cash Price	$84.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$78.75
Rate for Payer: Opus (Opus Packaging Group) HMA	$175.50
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$164.57
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$164.57
Rate for Payer: Priority Health Narrow/Tiered Network	$164.57
Rate for Payer: Priority Health Narrow/Tiered Network	$164.57

CHG US TRANSRCT PRSTATE VOL BRACHYTX PLNNING SPX

Professional

Both

$268.00

Service Code	HCPCS 76873
Min. Negotiated Rate	$134.00
Max. Negotiated Rate	$262.91
Rate for Payer: Aetna Commercial	$203.54
Rate for Payer: Aetna Medicare	$134.00
Rate for Payer: BCN Commercial	$260.94
Rate for Payer: Cash Price	$214.40
Rate for Payer: Cash Price	$214.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$201.00
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$262.91
Rate for Payer: Priority Health Narrow/Tiered Network	$262.91

CHG US TRANSRECTAL

Professional

Both

$73.00

Service Code	HCPCS 76872
Min. Negotiated Rate	$36.50
Max. Negotiated Rate	$295.52
Rate for Payer: Aetna Commercial	$158.29
Rate for Payer: Aetna Commercial	$158.29
Rate for Payer: Aetna Medicare	$36.50
Rate for Payer: Aetna Medicare	$171.00
Rate for Payer: BCN Commercial	$293.31
Rate for Payer: BCN Commercial	$293.31
Rate for Payer: Cash Price	$273.60
Rate for Payer: Cash Price	$273.60
Rate for Payer: Cash Price	$58.40
Rate for Payer: Cash Price	$58.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$256.50
Rate for Payer: Opus (Opus Packaging Group) HMA	$54.75
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$295.52
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$295.52
Rate for Payer: Priority Health Narrow/Tiered Network	$295.52
Rate for Payer: Priority Health Narrow/Tiered Network	$295.52

CHG US TRANSVAGINAL

Professional

Both

$319.00

Service Code	HCPCS 76830
Min. Negotiated Rate	$141.56
Max. Negotiated Rate	$239.25
Rate for Payer: Aetna Commercial	$141.56
Rate for Payer: Aetna Medicare	$159.50
Rate for Payer: BCN Commercial	$175.79
Rate for Payer: Cash Price	$255.20
Rate for Payer: Cash Price	$255.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$239.25
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$177.11
Rate for Payer: Priority Health Narrow/Tiered Network	$177.11

CHG US VASC ACCESS SITS VSL PATENCY NDL ENTRY

Professional

Both

$59.00

Service Code	HCPCS 76937
Min. Negotiated Rate	$29.50
Max. Negotiated Rate	$57.70
Rate for Payer: Aetna Commercial	$43.90
Rate for Payer: Aetna Commercial	$43.90
Rate for Payer: Aetna Medicare	$29.50
Rate for Payer: Aetna Medicare	$32.00
Rate for Payer: BCN Commercial	$57.27
Rate for Payer: BCN Commercial	$57.27
Rate for Payer: Cash Price	$51.20
Rate for Payer: Cash Price	$47.20
Rate for Payer: Cash Price	$51.20
Rate for Payer: Cash Price	$47.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$44.25
Rate for Payer: Opus (Opus Packaging Group) HMA	$48.00
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$57.70
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$57.70
Rate for Payer: Priority Health Narrow/Tiered Network	$57.70
Rate for Payer: Priority Health Narrow/Tiered Network	$57.70

CHG VENOGRAPHY ADRENAL UNILATERAL SELECTIVE RS&I

Professional

Both

$301.00

Service Code	HCPCS 75840
Min. Negotiated Rate	$150.50
Max. Negotiated Rate	$225.75
Rate for Payer: Aetna Commercial	$155.47
Rate for Payer: Aetna Medicare	$150.50
Rate for Payer: BCN Commercial	$191.23
Rate for Payer: Cash Price	$240.80
Rate for Payer: Cash Price	$240.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$225.75
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$192.66
Rate for Payer: Priority Health Narrow/Tiered Network	$192.66

CHG VENOGRAPHY CAVAL INFERIOR SERIALOGRAPHY RS&I

Professional

Both

$111.00

Service Code	HCPCS 75825
Min. Negotiated Rate	$55.50
Max. Negotiated Rate	$171.60
Rate for Payer: Aetna Commercial	$140.09
Rate for Payer: Aetna Medicare	$55.50
Rate for Payer: BCN Commercial	$170.31
Rate for Payer: Cash Price	$88.80
Rate for Payer: Cash Price	$88.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$83.25
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$171.60
Rate for Payer: Priority Health Narrow/Tiered Network	$171.60

CHG VENOGRAPHY CAVAL SUPERIOR SERIALOGRAPHY RS&I

Professional

Both

$108.00

Service Code	HCPCS 75827
Min. Negotiated Rate	$54.00
Max. Negotiated Rate	$176.61
Rate for Payer: Aetna Commercial	$146.19
Rate for Payer: Aetna Medicare	$54.00
Rate for Payer: BCN Commercial	$175.29
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	$176.61
Rate for Payer: Priority Health Narrow/Tiered Network	$176.61

CHG VENOGRAPHY EXTREMITY BILATERAL RS&I

Professional

Both

$282.00

Service Code	HCPCS 75822
Min. Negotiated Rate	$141.00
Max. Negotiated Rate	$211.50
Rate for Payer: Aetna Commercial	$163.45
Rate for Payer: Aetna Commercial	$163.45
Rate for Payer: Aetna Medicare	$73.00
Rate for Payer: Aetna Medicare	$141.00
Rate for Payer: BCN Commercial	$198.19
Rate for Payer: BCN Commercial	$198.19
Rate for Payer: Cash Price	$225.60
Rate for Payer: Cash Price	$116.80
Rate for Payer: Cash Price	$116.80
Rate for Payer: Cash Price	$225.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$211.50
Rate for Payer: Opus (Opus Packaging Group) HMA	$109.50
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$199.69
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$199.69
Rate for Payer: Priority Health Narrow/Tiered Network	$199.69
Rate for Payer: Priority Health Narrow/Tiered Network	$199.69

CHG VENOGRAPHY EXTREMITY UNILATERAL RS&I

Professional

Both

$111.00

Service Code	HCPCS 75820
Min. Negotiated Rate	$55.50
Max. Negotiated Rate	$159.55
Rate for Payer: Aetna Commercial	$135.80
Rate for Payer: Aetna Commercial	$135.80
Rate for Payer: Aetna Medicare	$55.50
Rate for Payer: Aetna Medicare	$119.00
Rate for Payer: BCN Commercial	$158.36
Rate for Payer: BCN Commercial	$158.36
Rate for Payer: Cash Price	$190.40
Rate for Payer: Cash Price	$88.80
Rate for Payer: Cash Price	$190.40
Rate for Payer: Cash Price	$88.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$83.25
Rate for Payer: Opus (Opus Packaging Group) HMA	$178.50
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$159.55
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$159.55
Rate for Payer: Priority Health Narrow/Tiered Network	$159.55
Rate for Payer: Priority Health Narrow/Tiered Network	$159.55

CHG VENOGRAPHY RENAL BILATERAL SELECTIVE RS&I

Professional

Both

$143.00

Service Code	HCPCS 75833
Min. Negotiated Rate	$71.50
Max. Negotiated Rate	$221.76
Rate for Payer: Aetna Commercial	$175.46
Rate for Payer: Aetna Medicare	$71.50
Rate for Payer: BCN Commercial	$220.11
Rate for Payer: Cash Price	$114.40
Rate for Payer: Cash Price	$114.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$107.25
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$221.76
Rate for Payer: Priority Health Narrow/Tiered Network	$221.76

CHG VENOGRAPHY RENAL UNILATERAL SELECTIVE RS&I

Professional

Both

$281.00

Service Code	HCPCS 75831
Min. Negotiated Rate	$140.50
Max. Negotiated Rate	$210.75
Rate for Payer: Aetna Commercial	$144.53
Rate for Payer: Aetna Commercial	$144.53
Rate for Payer: Aetna Medicare	$57.00
Rate for Payer: Aetna Medicare	$140.50
Rate for Payer: BCN Commercial	$178.77
Rate for Payer: BCN Commercial	$178.77
Rate for Payer: Cash Price	$224.80
Rate for Payer: Cash Price	$91.20
Rate for Payer: Cash Price	$91.20
Rate for Payer: Cash Price	$224.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$210.75
Rate for Payer: Opus (Opus Packaging Group) HMA	$85.50
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$180.12
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$180.12
Rate for Payer: Priority Health Narrow/Tiered Network	$180.12
Rate for Payer: Priority Health Narrow/Tiered Network	$180.12

CHG VENOGRAPHY VENOUS SINUS/JUGULAR CATH RS&I

Professional

Both

$289.00

Service Code	HCPCS 75860
Min. Negotiated Rate	$144.50
Max. Negotiated Rate	$216.75
Rate for Payer: Aetna Commercial	$153.68
Rate for Payer: Aetna Commercial	$153.68
Rate for Payer: Aetna Medicare	$144.50
Rate for Payer: Aetna Medicare	$188.50
Rate for Payer: BCN Commercial	$188.74
Rate for Payer: BCN Commercial	$188.74
Rate for Payer: Cash Price	$301.60
Rate for Payer: Cash Price	$231.20
Rate for Payer: Cash Price	$301.60
Rate for Payer: Cash Price	$231.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$216.75
Rate for Payer: Opus (Opus Packaging Group) HMA	$282.75
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$190.15
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$190.15
Rate for Payer: Priority Health Narrow/Tiered Network	$190.15
Rate for Payer: Priority Health Narrow/Tiered Network	$190.15

CHG VENOUS SAMPLING THRU CATH W/WO ANGIOGRAPHY RS&

Professional

Both

$344.00

Service Code	HCPCS 75893
Min. Negotiated Rate	$125.74
Max. Negotiated Rate	$258.00
Rate for Payer: Aetna Commercial	$125.74
Rate for Payer: Aetna Medicare	$172.00
Rate for Payer: BCN Commercial	$157.36
Rate for Payer: Cash Price	$275.20
Rate for Payer: Cash Price	$275.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$258.00
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$158.54
Rate for Payer: Priority Health Narrow/Tiered Network	$158.54

CHG VENOUS THROMBOSIS IMAGING VENOGRAM UNILATERAL

Professional

Both

$84.00

Service Code	HCPCS 78457
Min. Negotiated Rate	$42.00
Max. Negotiated Rate	$234.81
Rate for Payer: Aetna Commercial	$204.12
Rate for Payer: Aetna Commercial	$204.12
Rate for Payer: Aetna Medicare	$42.00
Rate for Payer: Aetna Medicare	$171.00
Rate for Payer: BCN Commercial	$233.06
Rate for Payer: BCN Commercial	$233.06
Rate for Payer: Cash Price	$273.60
Rate for Payer: Cash Price	$273.60
Rate for Payer: Cash Price	$67.20
Rate for Payer: Cash Price	$67.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$256.50
Rate for Payer: Opus (Opus Packaging Group) HMA	$63.00
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$234.81
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$234.81
Rate for Payer: Priority Health Narrow/Tiered Network	$234.81
Rate for Payer: Priority Health Narrow/Tiered Network	$234.81

CHG X-RAY ABDOMEN 1 VW

Professional

Both

$32.00

Service Code	HCPCS 74000
Min. Negotiated Rate	$12.80
Max. Negotiated Rate	$24.00
Rate for Payer: Aetna Medicare	$16.00
Rate for Payer: Aetna Medicare	$18.50
Rate for Payer: BCBS Complete	$12.80
Rate for Payer: BCBS Complete	$14.80
Rate for Payer: Cash Price	$25.60
Rate for Payer: Cash Price	$29.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$27.75
Rate for Payer: Opus (Opus Packaging Group) HMA	$24.00

CHG X-RAY ABDOMEN 2 VW

Professional

Both

$55.00

Service Code	HCPCS 74020
Min. Negotiated Rate	$22.00
Max. Negotiated Rate	$41.25
Rate for Payer: Aetna Medicare	$27.50
Rate for Payer: BCBS Complete	$22.00
Rate for Payer: Cash Price	$44.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$41.25

CHG X-RAY FEMUR 2 VW

Professional

Both

$39.00

Service Code	HCPCS 73550
Min. Negotiated Rate	$15.60
Max. Negotiated Rate	$29.25
Rate for Payer: Aetna Medicare	$19.50
Rate for Payer: Aetna Medicare	$15.50
Rate for Payer: Aetna Medicare	$48.50
Rate for Payer: BCBS Complete	$38.80
Rate for Payer: BCBS Complete	$12.40
Rate for Payer: BCBS Complete	$15.60
Rate for Payer: Cash Price	$77.60
Rate for Payer: Cash Price	$24.80
Rate for Payer: Cash Price	$31.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$29.25
Rate for Payer: Opus (Opus Packaging Group) HMA	$23.25
Rate for Payer: Opus (Opus Packaging Group) HMA	$72.75

CHG X-RAY HIPS 4 VW + PELVIS

Professional

Both

$48.00

Service Code	HCPCS 73520
Min. Negotiated Rate	$19.20
Max. Negotiated Rate	$36.00
Rate for Payer: Aetna Medicare	$24.00
Rate for Payer: Aetna Medicare	$62.50
Rate for Payer: Aetna Medicare	$28.00
Rate for Payer: BCBS Complete	$22.40
Rate for Payer: BCBS Complete	$19.20
Rate for Payer: BCBS Complete	$50.00
Rate for Payer: Cash Price	$44.80
Rate for Payer: Cash Price	$38.40
Rate for Payer: Cash Price	$100.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$93.75
Rate for Payer: Opus (Opus Packaging Group) HMA	$36.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$42.00

CHG X-RAY HIP UNI 2+ VW

Professional

Both

$103.00

Service Code	HCPCS 73510
Min. Negotiated Rate	$41.20
Max. Negotiated Rate	$77.25
Rate for Payer: Aetna Medicare	$51.50
Rate for Payer: Aetna Medicare	$28.00
Rate for Payer: Aetna Medicare	$19.00
Rate for Payer: BCBS Complete	$41.20
Rate for Payer: BCBS Complete	$22.40
Rate for Payer: BCBS Complete	$15.20
Rate for Payer: Cash Price	$30.40
Rate for Payer: Cash Price	$82.40
Rate for Payer: Cash Price	$44.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$77.25
Rate for Payer: Opus (Opus Packaging Group) HMA	$42.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$28.50

CHG X-RAY HIP UNILAT 1 VW

Professional

Both

$103.00

Service Code	HCPCS 73500
Min. Negotiated Rate	$41.20
Max. Negotiated Rate	$77.25
Rate for Payer: Aetna Medicare	$51.50
Rate for Payer: Aetna Medicare	$16.00
Rate for Payer: BCBS Complete	$12.80
Rate for Payer: BCBS Complete	$41.20
Rate for Payer: Cash Price	$82.40
Rate for Payer: Cash Price	$25.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$77.25
Rate for Payer: Opus (Opus Packaging Group) HMA	$24.00

CHG X-RAY PELVIS/HIPS CHILD/INFANT

Professional

Both

$100.00

Service Code	HCPCS 73540
Min. Negotiated Rate	$40.00
Max. Negotiated Rate	$75.00
Rate for Payer: Aetna Medicare	$50.00
Rate for Payer: Aetna Medicare	$18.00
Rate for Payer: BCBS Complete	$14.40
Rate for Payer: BCBS Complete	$40.00
Rate for Payer: Cash Price	$80.00
Rate for Payer: Cash Price	$28.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$75.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$27.00

CHG X-RAY SPINE SURVEY

Professional

Both

$75.00

Service Code	HCPCS 72010
Min. Negotiated Rate	$30.00
Max. Negotiated Rate	$56.25
Rate for Payer: Aetna Medicare	$37.50
Rate for Payer: BCBS Complete	$30.00
Rate for Payer: Cash Price	$60.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$56.25

Know your out-of-pocket cost for care.

All Charges