Bronson Methodist Hospital

All Charges

Charge

Type

Setting

Price

CHG THER RAD SIMULAJ-AIDED FIELD SETTING SIMPLE

Professional

Both

$435.00

Service Code	HCPCS 77280
Min. Negotiated Rate	$57.87
Max. Negotiated Rate	$1,443.32
Rate for Payer: Aetna Commercial	$319.36
Rate for Payer: Aetna Commercial	$319.36
Rate for Payer: BCBS Complete	$202.00
Rate for Payer: BCBS Complete	$174.00
Rate for Payer: BCBS Trust/PPO	$1,443.32
Rate for Payer: BCBS Trust/PPO	$1,443.32
Rate for Payer: Cash Price	$404.00
Rate for Payer: Cash Price	$348.00
Rate for Payer: Cash Price	$348.00
Rate for Payer: Cash Price	$404.00
Rate for Payer: Priority Health Cigna Priority Health	$353.50
Rate for Payer: Priority Health Cigna Priority Health	$304.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$57.87
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$57.87
Rate for Payer: Priority Health Narrow Network	$57.87
Rate for Payer: Priority Health Narrow Network	$57.87
Rate for Payer: Priority Health SBD	$413.32
Rate for Payer: Priority Health SBD	$413.32
Rate for Payer: UMR Bronson Commercial	$232.30
Rate for Payer: UMR Bronson Commercial	$200.10

CHG TISS CUL NON-NEO DISORDERS SKN/OTH SOLID TISS BX

Professional

Both

$293.00

Service Code	HCPCS 88233
Min. Negotiated Rate	$117.20
Max. Negotiated Rate	$215.54
Rate for Payer: Aetna Commercial	$133.69
Rate for Payer: BCBS Complete	$117.20
Rate for Payer: BCBS Trust/PPO	$183.85
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	$215.54
Rate for Payer: Priority Health Narrow Network	$215.54
Rate for Payer: Priority Health SBD	$215.54
Rate for Payer: UMR Bronson Commercial	$134.78

CHG TISS KOH SLIDE SAMPS SKN/HR/NLS FNGI/ECTOPARASIT

Professional

Both

$22.00

Service Code	HCPCS 87220
Min. Negotiated Rate	$4.06
Max. Negotiated Rate	$4,124.97
Rate for Payer: Aetna Commercial	$4.06
Rate for Payer: BCBS Complete	$8.80
Rate for Payer: BCBS Trust/PPO	$4,124.97
Rate for Payer: Cash Price	$17.60
Rate for Payer: Cash Price	$17.60
Rate for Payer: Priority Health Cigna Priority Health	$15.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$4.57
Rate for Payer: Priority Health Narrow Network	$4.57
Rate for Payer: Priority Health SBD	$4.57
Rate for Payer: UMR Bronson Commercial	$10.12

CHG TRANSCATHETER EMBOLIZATION ANY METH RS&I

Professional

Both

$352.00

Service Code	HCPCS 75894
Min. Negotiated Rate	$107.55
Max. Negotiated Rate	$1,537.01
Rate for Payer: Aetna Commercial	$1,126.65
Rate for Payer: BCBS Complete	$140.80
Rate for Payer: BCBS Trust/PPO	$393.58
Rate for Payer: Cash Price	$281.60
Rate for Payer: Cash Price	$281.60
Rate for Payer: Priority Health Cigna Priority Health	$246.40
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	$1,537.01
Rate for Payer: UMR Bronson Commercial	$161.92

CHG TRANSCATHETER INFUSION OTHER THAN THROMBOLYSIS

Professional

Both

$278.00

Service Code	HCPCS 75896
Min. Negotiated Rate	$111.20
Max. Negotiated Rate	$194.60
Rate for Payer: BCBS Complete	$111.20
Rate for Payer: Cash Price	$222.40
Rate for Payer: Priority Health Cigna Priority Health	$194.60
Rate for Payer: UMR Bronson Commercial	$127.88

CHG TRANSFERASE ALANINE AMINO ALT SGPT

Professional

Both

$14.00

Service Code	HCPCS 84460
Min. Negotiated Rate	$5.04
Max. Negotiated Rate	$1,976.37
Rate for Payer: Aetna Commercial	$5.04
Rate for Payer: BCBS Complete	$5.60
Rate for Payer: BCBS Trust/PPO	$1,976.37
Rate for Payer: Cash Price	$11.20
Rate for Payer: Cash Price	$11.20
Rate for Payer: Priority Health Cigna Priority Health	$9.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$5.62
Rate for Payer: Priority Health Narrow Network	$5.62
Rate for Payer: Priority Health SBD	$5.62
Rate for Payer: UMR Bronson Commercial	$6.44

CHG TRANSFERASE ASPARTATE AMINO AST SGOT

Professional

Both

$14.00

Service Code	HCPCS 84450
Min. Negotiated Rate	$4.92
Max. Negotiated Rate	$2,972.74
Rate for Payer: Aetna Commercial	$4.92
Rate for Payer: BCBS Complete	$5.60
Rate for Payer: BCBS Trust/PPO	$2,972.74
Rate for Payer: Cash Price	$11.20
Rate for Payer: Cash Price	$11.20
Rate for Payer: Priority Health Cigna Priority Health	$9.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$5.27
Rate for Payer: Priority Health Narrow Network	$5.27
Rate for Payer: Priority Health SBD	$5.27
Rate for Payer: UMR Bronson Commercial	$6.44

CHG TX DEVICES DESIGN & CONSTRUCTION COMPLEX

Professional

Both

$179.00

Service Code	HCPCS 77334
Min. Negotiated Rate	$71.60
Max. Negotiated Rate	$596.98
Rate for Payer: Aetna Commercial	$144.42
Rate for Payer: Aetna Commercial	$144.42
Rate for Payer: BCBS Complete	$71.60
Rate for Payer: BCBS Complete	$114.00
Rate for Payer: BCBS Trust/PPO	$596.98
Rate for Payer: BCBS Trust/PPO	$596.98
Rate for Payer: Cash Price	$143.20
Rate for Payer: Cash Price	$143.20
Rate for Payer: Cash Price	$228.00
Rate for Payer: Cash Price	$228.00
Rate for Payer: Priority Health Cigna Priority Health	$199.50
Rate for Payer: Priority Health Cigna Priority Health	$125.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$91.68
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$91.68
Rate for Payer: Priority Health Narrow Network	$91.68
Rate for Payer: Priority Health Narrow Network	$91.68
Rate for Payer: Priority Health SBD	$191.04
Rate for Payer: Priority Health SBD	$191.04
Rate for Payer: UMR Bronson Commercial	$131.10
Rate for Payer: UMR Bronson Commercial	$82.34

CHG TX DEVICES DESIGN & CONSTRUCTION INTERMEDIATE

Professional

Both

$90.00

Service Code	HCPCS 77333
Min. Negotiated Rate	$36.00
Max. Negotiated Rate	$828.16
Rate for Payer: Aetna Commercial	$151.32
Rate for Payer: Aetna Commercial	$151.32
Rate for Payer: BCBS Complete	$63.20
Rate for Payer: BCBS Complete	$36.00
Rate for Payer: BCBS Trust/PPO	$828.16
Rate for Payer: BCBS Trust/PPO	$828.16
Rate for Payer: Cash Price	$72.00
Rate for Payer: Cash Price	$126.40
Rate for Payer: Cash Price	$126.40
Rate for Payer: Cash Price	$72.00
Rate for Payer: Priority Health Cigna Priority Health	$63.00
Rate for Payer: Priority Health Cigna Priority Health	$110.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$60.44
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 Narrow Network	$60.44
Rate for Payer: Priority Health SBD	$211.02
Rate for Payer: Priority Health SBD	$211.02
Rate for Payer: UMR Bronson Commercial	$72.68
Rate for Payer: UMR Bronson Commercial	$41.40

CHG TX DEVICES DESIGN & CONSTRUCTION SIMPLE

Professional

Both

$97.00

Service Code	HCPCS 77332
Min. Negotiated Rate	$22.02
Max. Negotiated Rate	$828.16
Rate for Payer: Aetna Commercial	$48.30
Rate for Payer: Aetna Commercial	$48.30
Rate for Payer: BCBS Complete	$60.80
Rate for Payer: BCBS Complete	$38.80
Rate for Payer: BCBS Trust/PPO	$828.16
Rate for Payer: BCBS Trust/PPO	$828.16
Rate for Payer: Cash Price	$77.60
Rate for Payer: Cash Price	$121.60
Rate for Payer: Cash Price	$121.60
Rate for Payer: Cash Price	$77.60
Rate for Payer: Priority Health Cigna Priority Health	$106.40
Rate for Payer: Priority Health Cigna Priority Health	$67.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$22.02
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$22.02
Rate for Payer: Priority Health Narrow Network	$22.02
Rate for Payer: Priority Health Narrow Network	$22.02
Rate for Payer: Priority Health SBD	$58.38
Rate for Payer: Priority Health SBD	$58.38
Rate for Payer: UMR Bronson Commercial	$44.62
Rate for Payer: UMR Bronson Commercial	$69.92

CHG ULTRASONIC GUIDANCE INTRAOPERATIVE

Professional

Both

$289.00

Service Code	HCPCS 76998
Min. Negotiated Rate	$74.11
Max. Negotiated Rate	$202.30
Rate for Payer: Aetna Commercial	$74.11
Rate for Payer: BCBS Complete	$115.60
Rate for Payer: BCBS Trust/PPO	$125.74
Rate for Payer: Cash Price	$231.20
Rate for Payer: Cash Price	$231.20
Rate for Payer: Priority Health Cigna Priority Health	$202.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$92.71
Rate for Payer: Priority Health Narrow Network	$92.71
Rate for Payer: Priority Health SBD	$92.71
Rate for Payer: UMR Bronson Commercial	$132.94

CHG ULTRASOUND SPINAL CANAL & CONTENTS

Professional

Both

$89.00

Service Code	HCPCS 76800
Min. Negotiated Rate	$35.60
Max. Negotiated Rate	$337.06
Rate for Payer: Aetna Commercial	$164.90
Rate for Payer: BCBS Complete	$35.60
Rate for Payer: BCBS Trust/PPO	$337.06
Rate for Payer: Cash Price	$71.20
Rate for Payer: Cash Price	$71.20
Rate for Payer: Priority Health Cigna Priority Health	$62.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$92.19
Rate for Payer: Priority Health Narrow Network	$92.19
Rate for Payer: Priority Health SBD	$240.72
Rate for Payer: UMR Bronson Commercial	$40.94

CHG UNLISTED FLUOROSCOPIC PROCEDURE

Professional

Both

$250.00

Service Code	HCPCS 76496
Min. Negotiated Rate	$63.40
Max. Negotiated Rate	$175.00
Rate for Payer: Aetna Commercial	$74.70
Rate for Payer: BCBS Complete	$100.00
Rate for Payer: BCBS Trust/PPO	$63.40
Rate for Payer: Cash Price	$200.00
Rate for Payer: Cash Price	$200.00
Rate for Payer: Priority Health Cigna Priority Health	$175.00
Rate for Payer: UMR Bronson Commercial	$115.00

CHG URETERAL REFLUX STUDY RP VOIDING CYSTOGRAM

Professional

Both

$475.00

Service Code	HCPCS 78740
Min. Negotiated Rate	$39.43
Max. Negotiated Rate	$581.13
Rate for Payer: Aetna Commercial	$249.86
Rate for Payer: BCBS Complete	$190.00
Rate for Payer: BCBS Trust/PPO	$581.13
Rate for Payer: Cash Price	$380.00
Rate for Payer: Cash Price	$380.00
Rate for Payer: Priority Health Cigna Priority Health	$332.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$39.43
Rate for Payer: Priority Health Narrow Network	$39.43
Rate for Payer: Priority Health SBD	$312.42
Rate for Payer: UMR Bronson Commercial	$218.50

CHG URETHROCYSTOGRAPHY RETROGRADE RS&I

Professional

Both

$110.00

Service Code	HCPCS 74450
Min. Negotiated Rate	$24.08
Max. Negotiated Rate	$1,100.98
Rate for Payer: Aetna Commercial	$256.77
Rate for Payer: BCBS Complete	$44.00
Rate for Payer: BCBS Trust/PPO	$1,100.98
Rate for Payer: Cash Price	$88.00
Rate for Payer: Cash Price	$88.00
Rate for Payer: Priority Health Cigna Priority Health	$77.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$24.08
Rate for Payer: Priority Health Narrow Network	$24.08
Rate for Payer: Priority Health SBD	$104.48
Rate for Payer: UMR Bronson Commercial	$50.60

CHG URETHROCYSTOGRAPHY VOIDING RS&I

Professional

Both

$32.00

Service Code	HCPCS 74455
Min. Negotiated Rate	$12.80
Max. Negotiated Rate	$161.33
Rate for Payer: Aetna Commercial	$119.16
Rate for Payer: BCBS Complete	$12.80
Rate for Payer: BCBS Trust/PPO	$60.70
Rate for Payer: Cash Price	$25.60
Rate for Payer: Cash Price	$25.60
Rate for Payer: Priority Health Cigna Priority Health	$22.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$23.56
Rate for Payer: Priority Health Narrow Network	$23.56
Rate for Payer: Priority Health SBD	$161.33
Rate for Payer: UMR Bronson Commercial	$14.72

CHG URINALYSIS MICROSCOPIC ONLY

Professional

Both

$7.00

Service Code	HCPCS 81015
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$2,074.63
Rate for Payer: Aetna Commercial	$2.90
Rate for Payer: BCBS Complete	$2.80
Rate for Payer: BCBS Trust/PPO	$2,074.63
Rate for Payer: Cash Price	$5.60
Rate for Payer: Cash Price	$5.60
Rate for Payer: Priority Health Cigna Priority Health	$4.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$3.16
Rate for Payer: Priority Health Narrow Network	$3.16
Rate for Payer: Priority Health SBD	$3.16
Rate for Payer: UMR Bronson Commercial	$3.22

CHG URINALYSIS QUAL/SEMIQUANT EXCEPT IMMUNOASSAYS

Professional

Both

$14.00

Service Code	HCPCS 81005
Min. Negotiated Rate	$2.06
Max. Negotiated Rate	$2,140.67
Rate for Payer: Aetna Commercial	$2.06
Rate for Payer: BCBS Complete	$5.60
Rate for Payer: BCBS Trust/PPO	$2,140.67
Rate for Payer: Cash Price	$11.20
Rate for Payer: Cash Price	$11.20
Rate for Payer: Priority Health Cigna Priority Health	$9.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2.11
Rate for Payer: Priority Health Narrow Network	$2.11
Rate for Payer: Priority Health SBD	$2.11
Rate for Payer: UMR Bronson Commercial	$6.44

CHG URINARY BLADDER RESIDUAL STUDY

Professional

Both

$233.00

Service Code	HCPCS 78730
Min. Negotiated Rate	$10.76
Max. Negotiated Rate	$512.98
Rate for Payer: Aetna Commercial	$86.80
Rate for Payer: BCBS Complete	$93.20
Rate for Payer: BCBS Trust/PPO	$512.98
Rate for Payer: Cash Price	$186.40
Rate for Payer: Cash Price	$186.40
Rate for Payer: Priority Health Cigna Priority Health	$163.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$10.76
Rate for Payer: Priority Health Narrow Network	$10.76
Rate for Payer: Priority Health SBD	$104.48
Rate for Payer: UMR Bronson Commercial	$107.18

CHG URINE ALBUMIN SEMIQUANTITATIVE

Professional

Both

$14.00

Service Code	HCPCS 82044
Min. Negotiated Rate	$5.60
Max. Negotiated Rate	$3,544.36
Rate for Payer: Aetna Commercial	$5.92
Rate for Payer: BCBS Complete	$5.60
Rate for Payer: BCBS Trust/PPO	$3,544.36
Rate for Payer: Cash Price	$11.20
Rate for Payer: Cash Price	$11.20
Rate for Payer: Priority Health Cigna Priority Health	$9.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$6.33
Rate for Payer: Priority Health Narrow Network	$6.33
Rate for Payer: Priority Health SBD	$6.33
Rate for Payer: UMR Bronson Commercial	$6.44

CHG URINE PREGNANCY TEST VISUAL COLOR CMPRSN METHS

Professional

Both

$23.00

Service Code	HCPCS 81025
Min. Negotiated Rate	$8.18
Max. Negotiated Rate	$2,329.80
Rate for Payer: Aetna Commercial	$8.18
Rate for Payer: BCBS Complete	$9.20
Rate for Payer: BCBS Trust/PPO	$2,329.80
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	$8.78
Rate for Payer: Priority Health Narrow Network	$8.78
Rate for Payer: Priority Health SBD	$8.78
Rate for Payer: UMR Bronson Commercial	$10.58

CHG URINLS DIP STICK/TABLET REAGNT NON-AUTO MICRSCPY

Professional

Both

$17.00

Service Code	HCPCS 81000
Min. Negotiated Rate	$3.82
Max. Negotiated Rate	$2,458.18
Rate for Payer: Aetna Commercial	$3.82
Rate for Payer: BCBS Complete	$6.80
Rate for Payer: BCBS Trust/PPO	$2,458.18
Rate for Payer: Cash Price	$13.60
Rate for Payer: Cash Price	$13.60
Rate for Payer: Priority Health Cigna Priority Health	$11.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$4.22
Rate for Payer: Priority Health Narrow Network	$4.22
Rate for Payer: Priority Health SBD	$4.22
Rate for Payer: UMR Bronson Commercial	$7.82

CHG URNLS DIP STICK/TABLET REAGENT AUTO MICROSCOPY

Professional

Both

$30.00

Service Code	HCPCS 81001
Min. Negotiated Rate	$3.01
Max. Negotiated Rate	$3,145.50
Rate for Payer: Aetna Commercial	$3.01
Rate for Payer: BCBS Complete	$12.00
Rate for Payer: BCBS Trust/PPO	$3,145.50
Rate for Payer: Cash Price	$24.00
Rate for Payer: Cash Price	$24.00
Rate for Payer: Priority Health Cigna Priority Health	$21.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$3.16
Rate for Payer: Priority Health Narrow Network	$3.16
Rate for Payer: Priority Health SBD	$3.16
Rate for Payer: UMR Bronson Commercial	$13.80

CHG URNLS DIP STICK/TABLET RGNT AUTO W/O MICROSCOPY

Professional

Both

$14.00

Service Code	HCPCS 81003
Min. Negotiated Rate	$2.14
Max. Negotiated Rate	$1,827.92
Rate for Payer: Aetna Commercial	$2.14
Rate for Payer: BCBS Complete	$5.60
Rate for Payer: BCBS Trust/PPO	$1,827.92
Rate for Payer: Cash Price	$11.20
Rate for Payer: Cash Price	$11.20
Rate for Payer: Priority Health Cigna Priority Health	$9.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2.46
Rate for Payer: Priority Health Narrow Network	$2.46
Rate for Payer: Priority Health SBD	$2.46
Rate for Payer: UMR Bronson Commercial	$6.44

CHG URNLS DIP STICK/TABLET RGNT NON-AUTO W/O MICRSCP

Professional

Both

$12.00

Service Code	HCPCS 81002
Min. Negotiated Rate	$3.31
Max. Negotiated Rate	$2,102.11
Rate for Payer: Aetna Commercial	$3.31
Rate for Payer: BCBS Complete	$4.80
Rate for Payer: BCBS Trust/PPO	$2,102.11
Rate for Payer: Cash Price	$9.60
Rate for Payer: Cash Price	$9.60
Rate for Payer: Priority Health Cigna Priority Health	$8.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$3.52
Rate for Payer: Priority Health Narrow Network	$3.52
Rate for Payer: Priority Health SBD	$3.52
Rate for Payer: UMR Bronson Commercial	$5.52

Know your out-of-pocket cost for care.

All Charges