Bronson Methodist Hospital

All Charges

Charge

Type

Setting

Price

CHG MRI BRAIN BRAIN STEM W/CONTRAST MATERIAL

Professional

Both

$370.00

Service Code	HCPCS 70552
Min. Negotiated Rate	$129.57
Max. Negotiated Rate	$1,113.66
Rate for Payer: Aetna Commercial	$442.56
Rate for Payer: BCBS Complete	$148.00
Rate for Payer: BCBS Trust/PPO	$1,113.66
Rate for Payer: Cash Price	$296.00
Rate for Payer: Cash Price	$296.00
Rate for Payer: Priority Health Cigna Priority Health	$259.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$129.57
Rate for Payer: Priority Health Narrow Network	$129.57
Rate for Payer: Priority Health SBD	$433.30
Rate for Payer: UMR Bronson Commercial	$170.20

CHG MRI BRAIN BRAIN STEM W/O CONTRAST MATERIAL

Professional

Both

$319.00

Service Code	HCPCS 70551
Min. Negotiated Rate	$107.55
Max. Negotiated Rate	$2,070.41
Rate for Payer: Aetna Commercial	$318.81
Rate for Payer: BCBS Complete	$127.60
Rate for Payer: BCBS Trust/PPO	$2,070.41
Rate for Payer: Cash Price	$255.20
Rate for Payer: Cash Price	$255.20
Rate for Payer: Priority Health Cigna Priority Health	$223.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$107.55
Rate for Payer: Priority Health Narrow Network	$107.55
Rate for Payer: Priority Health SBD	$312.93
Rate for Payer: UMR Bronson Commercial	$146.74

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

Professional

Both

$341.00

Service Code	HCPCS 70553
Min. Negotiated Rate	$136.40
Max. Negotiated Rate	$968.37
Rate for Payer: Aetna Commercial	$523.42
Rate for Payer: BCBS Complete	$136.40
Rate for Payer: BCBS Trust/PPO	$968.37
Rate for Payer: Cash Price	$272.80
Rate for Payer: Cash Price	$272.80
Rate for Payer: Priority Health Cigna Priority Health	$238.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$165.94
Rate for Payer: Priority Health Narrow Network	$165.94
Rate for Payer: Priority Health SBD	$510.12
Rate for Payer: UMR Bronson Commercial	$156.86

CHG MRI SPINAL CANAL CERVICAL W/O CONTRAST MATRL

Professional

Both

$296.00

Service Code	HCPCS 72141
Min. Negotiated Rate	$107.55
Max. Negotiated Rate	$3,028.22
Rate for Payer: Aetna Commercial	$311.87
Rate for Payer: BCBS Complete	$118.40
Rate for Payer: BCBS Trust/PPO	$3,028.22
Rate for Payer: Cash Price	$236.80
Rate for Payer: Cash Price	$236.80
Rate for Payer: Priority Health Cigna Priority Health	$207.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$107.55
Rate for Payer: Priority Health Narrow Network	$107.55
Rate for Payer: Priority Health SBD	$304.23
Rate for Payer: UMR Bronson Commercial	$136.16

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

Professional

Both

$308.00

Service Code	HCPCS 72156
Min. Negotiated Rate	$123.20
Max. Negotiated Rate	$3,620.44
Rate for Payer: Aetna Commercial	$528.35
Rate for Payer: BCBS Complete	$123.20
Rate for Payer: BCBS Trust/PPO	$3,620.44
Rate for Payer: Cash Price	$246.40
Rate for Payer: Cash Price	$246.40
Rate for Payer: Priority Health Cigna Priority Health	$215.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$165.94
Rate for Payer: Priority Health Narrow Network	$165.94
Rate for Payer: Priority Health SBD	$512.68
Rate for Payer: UMR Bronson Commercial	$141.68

CHG MRI SPINAL CANAL LUMBAR W/CONTRAST MATERIAL

Professional

Both

$321.00

Service Code	HCPCS 72149
Min. Negotiated Rate	$128.40
Max. Negotiated Rate	$3,237.95
Rate for Payer: Aetna Commercial	$446.00
Rate for Payer: BCBS Complete	$128.40
Rate for Payer: BCBS Trust/PPO	$3,237.95
Rate for Payer: Cash Price	$256.80
Rate for Payer: Cash Price	$256.80
Rate for Payer: Priority Health Cigna Priority Health	$224.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$129.57
Rate for Payer: Priority Health Narrow Network	$129.57
Rate for Payer: Priority Health SBD	$433.30
Rate for Payer: UMR Bronson Commercial	$147.66

CHG MRI SPINAL CANAL LUMBAR W/O CONTRAST MATERIAL

Professional

Both

$242.00

Service Code	HCPCS 72148
Min. Negotiated Rate	$96.80
Max. Negotiated Rate	$3,385.35
Rate for Payer: Aetna Commercial	$312.37
Rate for Payer: BCBS Complete	$96.80
Rate for Payer: BCBS Trust/PPO	$3,385.35
Rate for Payer: Cash Price	$193.60
Rate for Payer: Cash Price	$193.60
Rate for Payer: Priority Health Cigna Priority Health	$169.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$107.55
Rate for Payer: Priority Health Narrow Network	$107.55
Rate for Payer: Priority Health SBD	$305.26
Rate for Payer: UMR Bronson Commercial	$111.32

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

Professional

Both

$293.00

Service Code	HCPCS 72158
Min. Negotiated Rate	$117.20
Max. Negotiated Rate	$3,525.87
Rate for Payer: Aetna Commercial	$527.37
Rate for Payer: BCBS Complete	$117.20
Rate for Payer: BCBS Trust/PPO	$3,525.87
Rate for Payer: Cash Price	$234.40
Rate for Payer: Cash Price	$234.40
Rate for Payer: Priority Health Cigna Priority Health	$205.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$165.94
Rate for Payer: Priority Health Narrow Network	$165.94
Rate for Payer: Priority Health SBD	$511.65
Rate for Payer: UMR Bronson Commercial	$134.78

CHG MRI SPINAL CANAL THORACIC W/O CONTRAST MATRL

Professional

Both

$267.00

Service Code	HCPCS 72146
Min. Negotiated Rate	$106.80
Max. Negotiated Rate	$2,911.46
Rate for Payer: Aetna Commercial	$311.87
Rate for Payer: BCBS Complete	$106.80
Rate for Payer: BCBS Trust/PPO	$2,911.46
Rate for Payer: Cash Price	$213.60
Rate for Payer: Cash Price	$213.60
Rate for Payer: Priority Health Cigna Priority Health	$186.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$107.55
Rate for Payer: Priority Health Narrow Network	$107.55
Rate for Payer: Priority Health SBD	$304.23
Rate for Payer: UMR Bronson Commercial	$122.82

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

Professional

Both

$324.00

Service Code	HCPCS 72157
Min. Negotiated Rate	$129.60
Max. Negotiated Rate	$3,439.76
Rate for Payer: Aetna Commercial	$529.34
Rate for Payer: BCBS Complete	$129.60
Rate for Payer: BCBS Trust/PPO	$3,439.76
Rate for Payer: Cash Price	$259.20
Rate for Payer: Cash Price	$259.20
Rate for Payer: Priority Health Cigna Priority Health	$226.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$165.94
Rate for Payer: Priority Health Narrow Network	$165.94
Rate for Payer: Priority Health SBD	$513.71
Rate for Payer: UMR Bronson Commercial	$149.04

CHG MYELOGRAPY LUMBOSACRAL RS&I

Professional

Both

$160.00

Service Code	HCPCS 72265
Min. Negotiated Rate	$60.44
Max. Negotiated Rate	$3,085.27
Rate for Payer: Aetna Commercial	$124.16
Rate for Payer: BCBS Complete	$64.00
Rate for Payer: BCBS Trust/PPO	$3,085.27
Rate for Payer: Cash Price	$128.00
Rate for Payer: Cash Price	$128.00
Rate for Payer: Priority Health Cigna Priority Health	$112.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$60.44
Rate for Payer: Priority Health Narrow Network	$60.44
Rate for Payer: Priority Health SBD	$168.50
Rate for Payer: UMR Bronson Commercial	$73.60

CHG MYOCARDIAL PERFUSION PLANAR 1 STUDY REST/STRESS

Professional

Both

$120.00

Service Code	HCPCS 78453
Min. Negotiated Rate	$48.00
Max. Negotiated Rate	$417.93
Rate for Payer: Aetna Commercial	$339.63
Rate for Payer: BCBS Complete	$48.00
Rate for Payer: BCBS Trust/PPO	$240.38
Rate for Payer: Cash Price	$96.00
Rate for Payer: Cash Price	$96.00
Rate for Payer: Priority Health Cigna Priority Health	$84.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$70.17
Rate for Payer: Priority Health Narrow Network	$70.17
Rate for Payer: Priority Health SBD	$417.93
Rate for Payer: UMR Bronson Commercial	$55.20

CHG MYOCARDIAL PERFUSION PLANAR MULTIPLE STUDIES

Professional

Both

$155.00

Service Code	HCPCS 78454
Min. Negotiated Rate	$62.00
Max. Negotiated Rate	$623.31
Rate for Payer: Aetna Commercial	$490.87
Rate for Payer: BCBS Complete	$62.00
Rate for Payer: BCBS Trust/PPO	$256.75
Rate for Payer: Cash Price	$124.00
Rate for Payer: Cash Price	$124.00
Rate for Payer: Priority Health Cigna Priority Health	$108.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$96.80
Rate for Payer: Priority Health Narrow Network	$96.80
Rate for Payer: Priority Health SBD	$623.31
Rate for Payer: UMR Bronson Commercial	$71.30

CHG MYOCARDIAL SPECT MULTIPLE STUDIES

Professional

Both

$188.00

Service Code	HCPCS 78452
Min. Negotiated Rate	$75.20
Max. Negotiated Rate	$671.45
Rate for Payer: Aetna Commercial	$538.09
Rate for Payer: Aetna Commercial	$538.09
Rate for Payer: BCBS Complete	$75.20
Rate for Payer: BCBS Complete	$359.20
Rate for Payer: BCBS Trust/PPO	$209.21
Rate for Payer: BCBS Trust/PPO	$209.21
Rate for Payer: Cash Price	$150.40
Rate for Payer: Cash Price	$718.40
Rate for Payer: Cash Price	$718.40
Rate for Payer: Cash Price	$150.40
Rate for Payer: Priority Health Cigna Priority Health	$131.60
Rate for Payer: Priority Health Cigna Priority Health	$628.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$114.73
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$114.73
Rate for Payer: Priority Health Narrow Network	$114.73
Rate for Payer: Priority Health Narrow Network	$114.73
Rate for Payer: Priority Health SBD	$671.45
Rate for Payer: Priority Health SBD	$671.45
Rate for Payer: UMR Bronson Commercial	$413.08
Rate for Payer: UMR Bronson Commercial	$86.48

CHG MYOCARDIAL SPECT SINGLE STUDY AT REST OR STRESS

Professional

Both

$165.00

Service Code	HCPCS 78451
Min. Negotiated Rate	$66.00
Max. Negotiated Rate	$517.21
Rate for Payer: Aetna Commercial	$387.26
Rate for Payer: BCBS Complete	$66.00
Rate for Payer: BCBS Trust/PPO	$517.21
Rate for Payer: Cash Price	$132.00
Rate for Payer: Cash Price	$132.00
Rate for Payer: Priority Health Cigna Priority Health	$115.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$96.80
Rate for Payer: Priority Health Narrow Network	$96.80
Rate for Payer: Priority Health SBD	$483.99
Rate for Payer: UMR Bronson Commercial	$75.90

CHG MYOCRD IMG PET PRFUJ SINGLE STUDY REST/STRESS

Professional

Both

$700.00

Service Code	HCPCS 78491
Min. Negotiated Rate	$106.54
Max. Negotiated Rate	$1,378.75
Rate for Payer: Aetna Commercial	$1,378.75
Rate for Payer: BCBS Complete	$280.00
Rate for Payer: BCBS Trust/PPO	$431.09
Rate for Payer: Cash Price	$560.00
Rate for Payer: Cash Price	$560.00
Rate for Payer: Priority Health Cigna Priority Health	$490.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$106.54
Rate for Payer: Priority Health Narrow Network	$106.54
Rate for Payer: Priority Health SBD	$665.81
Rate for Payer: UMR Bronson Commercial	$322.00

CHG NTSTY MODUL RADTHX PLN DOSE-VOL HISTOS

Professional

Both

$1,718.00

Service Code	HCPCS 77301
Min. Negotiated Rate	$603.85
Max. Negotiated Rate	$2,813.85
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: BCBS Complete	$1,498.00
Rate for Payer: BCBS Complete	$687.20
Rate for Payer: BCBS Complete	$1,204.40
Rate for Payer: BCBS Trust/PPO	$603.85
Rate for Payer: BCBS Trust/PPO	$603.85
Rate for Payer: BCBS Trust/PPO	$603.85
Rate for Payer: Cash Price	$2,408.80
Rate for Payer: Cash Price	$1,374.40
Rate for Payer: Cash Price	$1,374.40
Rate for Payer: Cash Price	$2,408.80
Rate for Payer: Cash Price	$2,996.00
Rate for Payer: Cash Price	$2,996.00
Rate for Payer: Priority Health Cigna Priority Health	$2,107.70
Rate for Payer: Priority Health Cigna Priority Health	$1,202.60
Rate for Payer: Priority Health Cigna Priority Health	$2,621.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$639.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$639.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$639.70
Rate for Payer: Priority Health Narrow Network	$639.70
Rate for Payer: Priority Health Narrow Network	$639.70
Rate for Payer: Priority Health Narrow Network	$639.70
Rate for Payer: Priority Health SBD	$2,813.85
Rate for Payer: Priority Health SBD	$2,813.85
Rate for Payer: Priority Health SBD	$2,813.85
Rate for Payer: UMR Bronson Commercial	$1,385.06
Rate for Payer: UMR Bronson Commercial	$790.28
Rate for Payer: UMR Bronson Commercial	$1,722.70

CHG OPH BMTRY US ECHOGRAPY A-SCAN IO LENS PWR CAL

Professional

Both

$48.00

Service Code	HCPCS 76519
Min. Negotiated Rate	$19.20
Max. Negotiated Rate	$2,288.07
Rate for Payer: Aetna Commercial	$76.83
Rate for Payer: BCBS Complete	$19.20
Rate for Payer: BCBS Trust/PPO	$2,288.07
Rate for Payer: Cash Price	$38.40
Rate for Payer: Cash Price	$38.40
Rate for Payer: Priority Health Cigna Priority Health	$33.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$45.58
Rate for Payer: Priority Health Narrow Network	$45.58
Rate for Payer: Priority Health SBD	$102.94
Rate for Payer: UMR Bronson Commercial	$22.08

CHG OPHTHALMIC US DX CORNEAL PACHYMETRY UNI/BI

Professional

Both

$23.00

Service Code	HCPCS 76514
Min. Negotiated Rate	$5.64
Max. Negotiated Rate	$1,479.24
Rate for Payer: Aetna Commercial	$13.55
Rate for Payer: BCBS Complete	$9.20
Rate for Payer: BCBS Trust/PPO	$1,479.24
Rate for Payer: Cash Price	$18.40
Rate for Payer: Cash Price	$18.40
Rate for Payer: Priority Health Cigna Priority Health	$16.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$5.64
Rate for Payer: Priority Health Narrow Network	$5.64
Rate for Payer: Priority Health SBD	$17.41
Rate for Payer: UMR Bronson Commercial	$10.58

CHG PARTICLE AGGLUTINATION SCREEN EACH ANTIBODY

Professional

Both

$21.00

Service Code	HCPCS 86403
Min. Negotiated Rate	$8.40
Max. Negotiated Rate	$1,738.64
Rate for Payer: Aetna Commercial	$10.96
Rate for Payer: BCBS Complete	$8.40
Rate for Payer: BCBS Trust/PPO	$1,738.64
Rate for Payer: Cash Price	$16.80
Rate for Payer: Cash Price	$16.80
Rate for Payer: Priority Health Cigna Priority Health	$14.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$11.95
Rate for Payer: Priority Health Narrow Network	$11.95
Rate for Payer: Priority Health SBD	$11.95
Rate for Payer: UMR Bronson Commercial	$9.66

CHG PERCUTANEOUS VERTEBROPLASTY, CT GUIDE

Professional

Both

$262.00

Service Code	HCPCS 72292
Min. Negotiated Rate	$104.80
Max. Negotiated Rate	$183.40
Rate for Payer: BCBS Complete	$104.80
Rate for Payer: Cash Price	$209.60
Rate for Payer: Priority Health Cigna Priority Health	$183.40
Rate for Payer: UMR Bronson Commercial	$120.52

CHG PERCUTANEOUS VERTEBROPLASTY, FLUOR GUIDE

Professional

Both

$237.00

Service Code	HCPCS 72291
Min. Negotiated Rate	$94.80
Max. Negotiated Rate	$165.90
Rate for Payer: BCBS Complete	$94.80
Rate for Payer: Cash Price	$189.60
Rate for Payer: Priority Health Cigna Priority Health	$165.90
Rate for Payer: UMR Bronson Commercial	$109.02

CHG PERITONEOGRAM RS&I

Professional

Both

$45.00

Service Code	HCPCS 74190
Min. Negotiated Rate	$18.00
Max. Negotiated Rate	$2,754.03
Rate for Payer: Aetna Commercial	$534.94
Rate for Payer: BCBS Complete	$18.00
Rate for Payer: BCBS Trust/PPO	$2,754.03
Rate for Payer: Cash Price	$36.00
Rate for Payer: Cash Price	$36.00
Rate for Payer: Priority Health Cigna Priority Health	$31.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$33.81
Rate for Payer: Priority Health Narrow Network	$33.81
Rate for Payer: Priority Health SBD	$84.50
Rate for Payer: UMR Bronson Commercial	$20.70

CHG PH BODY FLUID NOT ELSEWHERE SPECIFIED

Professional

Both

$15.00

Service Code	HCPCS 83986
Min. Negotiated Rate	$3.40
Max. Negotiated Rate	$4,440.36
Rate for Payer: Aetna Commercial	$3.40
Rate for Payer: BCBS Complete	$6.00
Rate for Payer: BCBS Trust/PPO	$4,440.36
Rate for Payer: Cash Price	$12.00
Rate for Payer: Cash Price	$12.00
Rate for Payer: Priority Health Cigna Priority Health	$10.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$3.87
Rate for Payer: Priority Health Narrow Network	$3.87
Rate for Payer: Priority Health SBD	$3.87
Rate for Payer: UMR Bronson Commercial	$6.90

CHG PLACEMNT,PROX/DIST EXT PROS, INFRARENAL

Professional

Both

$446.00

Service Code	HCPCS 75953
Min. Negotiated Rate	$178.40
Max. Negotiated Rate	$312.20
Rate for Payer: BCBS Complete	$178.40
Rate for Payer: Cash Price	$356.80
Rate for Payer: Priority Health Cigna Priority Health	$312.20
Rate for Payer: UMR Bronson Commercial	$205.16

Know your out-of-pocket cost for care.

All Charges