Bronson Methodist Hospital

All Charges

Charge

Type

Setting

Price

CHG UROGRAPHY IV W/WO KUB W/WO TOMOGRAPHY

Professional

Both

$209.00

Service Code	HCPCS 74400
Min. Negotiated Rate	$35.85
Max. Negotiated Rate	$673.05
Rate for Payer: Aetna Commercial	$153.73
Rate for Payer: Aetna Commercial	$153.73
Rate for Payer: BCBS Complete	$83.60
Rate for Payer: BCBS Complete	$54.80
Rate for Payer: BCBS Trust/PPO	$673.05
Rate for Payer: BCBS Trust/PPO	$673.05
Rate for Payer: Cash Price	$167.20
Rate for Payer: Cash Price	$109.60
Rate for Payer: Cash Price	$109.60
Rate for Payer: Cash Price	$167.20
Rate for Payer: Priority Health Cigna Priority Health	$95.90
Rate for Payer: Priority Health Cigna Priority Health	$146.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$35.85
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$35.85
Rate for Payer: Priority Health Narrow Network	$35.85
Rate for Payer: Priority Health Narrow Network	$35.85
Rate for Payer: Priority Health SBD	$209.99
Rate for Payer: Priority Health SBD	$209.99
Rate for Payer: UMR Bronson Commercial	$63.02
Rate for Payer: UMR Bronson Commercial	$96.14

CHG UROGRAPHY RETROGRADE WITH/WO KUB

Professional

Both

$58.00

Service Code	HCPCS 74420
Min. Negotiated Rate	$23.20
Max. Negotiated Rate	$978.41
Rate for Payer: Aetna Commercial	$87.47
Rate for Payer: BCBS Complete	$23.20
Rate for Payer: BCBS Trust/PPO	$978.41
Rate for Payer: Cash Price	$46.40
Rate for Payer: Cash Price	$46.40
Rate for Payer: Priority Health Cigna Priority Health	$40.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$36.88
Rate for Payer: Priority Health Narrow Network	$36.88
Rate for Payer: Priority Health SBD	$118.31
Rate for Payer: UMR Bronson Commercial	$26.68

CHG US ABDOMINAL REAL TIME W/IMAGE DOCUMENTATION

Professional

Both

$209.00

Service Code	HCPCS 76700
Min. Negotiated Rate	$58.38
Max. Negotiated Rate	$2,008.07
Rate for Payer: Aetna Commercial	$139.34
Rate for Payer: BCBS Complete	$83.60
Rate for Payer: BCBS Trust/PPO	$2,008.07
Rate for Payer: Cash Price	$167.20
Rate for Payer: Cash Price	$167.20
Rate for Payer: Priority Health Cigna Priority Health	$146.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$58.38
Rate for Payer: Priority Health Narrow Network	$58.38
Rate for Payer: Priority Health SBD	$179.76
Rate for Payer: UMR Bronson Commercial	$96.14

CHG US ABDOMINAL REAL TIME W/IMAGE LIMITED

Professional

Both

$176.00

Service Code	HCPCS 76705
Min. Negotiated Rate	$43.03
Max. Negotiated Rate	$2,317.65
Rate for Payer: Aetna Commercial	$104.19
Rate for Payer: Aetna Commercial	$104.19
Rate for Payer: BCBS Complete	$42.40
Rate for Payer: BCBS Complete	$70.40
Rate for Payer: BCBS Trust/PPO	$2,317.65
Rate for Payer: BCBS Trust/PPO	$2,317.65
Rate for Payer: Cash Price	$140.80
Rate for Payer: Cash Price	$84.80
Rate for Payer: Cash Price	$140.80
Rate for Payer: Cash Price	$84.80
Rate for Payer: Priority Health Cigna Priority Health	$74.20
Rate for Payer: Priority Health Cigna Priority Health	$123.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$43.03
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$43.03
Rate for Payer: Priority Health Narrow Network	$43.03
Rate for Payer: Priority Health Narrow Network	$43.03
Rate for Payer: Priority Health SBD	$135.72
Rate for Payer: Priority Health SBD	$135.72
Rate for Payer: UMR Bronson Commercial	$48.76
Rate for Payer: UMR Bronson Commercial	$80.96

CHG US, BREAST(S), REAL TIME

Professional

Both

$147.00

Service Code	HCPCS 76645
Min. Negotiated Rate	$58.80
Max. Negotiated Rate	$102.90
Rate for Payer: BCBS Complete	$58.80
Rate for Payer: Cash Price	$117.60
Rate for Payer: Priority Health Cigna Priority Health	$102.90
Rate for Payer: UMR Bronson Commercial	$67.62

CHG US CHEST REAL TIME W/IMAGE DOCUMENTATION

Professional

Both

$56.00

Service Code	HCPCS 76604
Min. Negotiated Rate	$22.40
Max. Negotiated Rate	$2,617.20
Rate for Payer: Aetna Commercial	$77.11
Rate for Payer: BCBS Complete	$22.40
Rate for Payer: BCBS Trust/PPO	$2,617.20
Rate for Payer: Cash Price	$44.80
Rate for Payer: Cash Price	$44.80
Rate for Payer: Priority Health Cigna Priority Health	$39.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$42.00
Rate for Payer: Priority Health Narrow Network	$42.00
Rate for Payer: Priority Health SBD	$87.07
Rate for Payer: UMR Bronson Commercial	$25.76

CHG US CMPRN RPR ARTL PSEUDOARYSM/ARVEN FSTL

Professional

Both

$421.00

Service Code	HCPCS 76936
Min. Negotiated Rate	$141.36
Max. Negotiated Rate	$397.44
Rate for Payer: Aetna Commercial	$310.24
Rate for Payer: BCBS Complete	$168.40
Rate for Payer: BCBS Trust/PPO	$293.21
Rate for Payer: Cash Price	$336.80
Rate for Payer: Cash Price	$336.80
Rate for Payer: Priority Health Cigna Priority Health	$294.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$141.36
Rate for Payer: Priority Health Narrow Network	$141.36
Rate for Payer: Priority Health SBD	$397.44
Rate for Payer: UMR Bronson Commercial	$193.66

CHG US COMPL JOINT R-T W/IMAGE DOCUMENTATION

Professional

Both

$84.00

Service Code	HCPCS 76881
Min. Negotiated Rate	$16.90
Max. Negotiated Rate	$763.39
Rate for Payer: Aetna Commercial	$76.43
Rate for Payer: Aetna Commercial	$76.43
Rate for Payer: BCBS Complete	$33.60
Rate for Payer: BCBS Complete	$121.60
Rate for Payer: BCBS Trust/PPO	$763.39
Rate for Payer: BCBS Trust/PPO	$763.39
Rate for Payer: Cash Price	$243.20
Rate for Payer: Cash Price	$67.20
Rate for Payer: Cash Price	$67.20
Rate for Payer: Cash Price	$243.20
Rate for Payer: Priority Health Cigna Priority Health	$58.80
Rate for Payer: Priority Health Cigna Priority Health	$212.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$16.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$16.90
Rate for Payer: Priority Health Narrow Network	$16.90
Rate for Payer: Priority Health Narrow Network	$16.90
Rate for Payer: Priority Health SBD	$82.46
Rate for Payer: Priority Health SBD	$82.46
Rate for Payer: UMR Bronson Commercial	$38.64
Rate for Payer: UMR Bronson Commercial	$139.84

CHG US FETAL NUCHAL TRANSLUCENCY 1ST GESTATION

Professional

Both

$286.00

Service Code	HCPCS 76813
Min. Negotiated Rate	$86.04
Max. Negotiated Rate	$675.17
Rate for Payer: Aetna Commercial	$140.72
Rate for Payer: BCBS Complete	$114.40
Rate for Payer: BCBS Trust/PPO	$675.17
Rate for Payer: Cash Price	$228.80
Rate for Payer: Cash Price	$228.80
Rate for Payer: Priority Health Cigna Priority Health	$200.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$86.04
Rate for Payer: Priority Health Narrow Network	$86.04
Rate for Payer: Priority Health SBD	$180.28
Rate for Payer: UMR Bronson Commercial	$131.56

CHG US FETAL NUCHAL TRANSLUCENCY EA ADDL GESTATION

Professional

Both

$191.00

Service Code	HCPCS 76814
Min. Negotiated Rate	$43.53
Max. Negotiated Rate	$696.30
Rate for Payer: Aetna Commercial	$91.18
Rate for Payer: BCBS Complete	$76.40
Rate for Payer: BCBS Trust/PPO	$696.30
Rate for Payer: Cash Price	$152.80
Rate for Payer: Cash Price	$152.80
Rate for Payer: Priority Health Cigna Priority Health	$133.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$43.53
Rate for Payer: Priority Health Narrow Network	$43.53
Rate for Payer: Priority Health SBD	$114.73
Rate for Payer: UMR Bronson Commercial	$87.86

CHG US GUIDANCE AMNIOCENTESIS IMG S&I

Professional

Both

$314.00

Service Code	HCPCS 76946
Min. Negotiated Rate	$22.53
Max. Negotiated Rate	$219.80
Rate for Payer: Aetna Commercial	$37.71
Rate for Payer: BCBS Complete	$125.60
Rate for Payer: BCBS Trust/PPO	$194.41
Rate for Payer: Cash Price	$251.20
Rate for Payer: Cash Price	$251.20
Rate for Payer: Priority Health Cigna Priority Health	$219.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$22.53
Rate for Payer: Priority Health Narrow Network	$22.53
Rate for Payer: Priority Health SBD	$50.19
Rate for Payer: UMR Bronson Commercial	$144.44

CHG US GUIDANCE INTERSTITIAL RADIOELMENT APPLICATION

Professional

Both

$262.00

Service Code	HCPCS 76965
Min. Negotiated Rate	$41.49
Max. Negotiated Rate	$183.40
Rate for Payer: Aetna Commercial	$108.13
Rate for Payer: Aetna Commercial	$108.13
Rate for Payer: BCBS Complete	$104.80
Rate for Payer: BCBS Complete	$148.80
Rate for Payer: BCBS Trust/PPO	$133.13
Rate for Payer: BCBS Trust/PPO	$133.13
Rate for Payer: Cash Price	$209.60
Rate for Payer: Cash Price	$209.60
Rate for Payer: Cash Price	$297.60
Rate for Payer: Cash Price	$297.60
Rate for Payer: Priority Health Cigna Priority Health	$183.40
Rate for Payer: Priority Health Cigna Priority Health	$260.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$41.49
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$41.49
Rate for Payer: Priority Health Narrow Network	$41.49
Rate for Payer: Priority Health Narrow Network	$41.49
Rate for Payer: Priority Health SBD	$142.90
Rate for Payer: Priority Health SBD	$142.90
Rate for Payer: UMR Bronson Commercial	$171.12
Rate for Payer: UMR Bronson Commercial	$120.52

CHG US GUIDANCE NEEDLE PLACEMENT IMG S&I

Professional

Both

$457.00

Service Code	HCPCS 76942
Min. Negotiated Rate	$43.03
Max. Negotiated Rate	$319.90
Rate for Payer: Aetna Commercial	$67.10
Rate for Payer: Aetna Commercial	$67.10
Rate for Payer: BCBS Complete	$44.40
Rate for Payer: BCBS Complete	$182.80
Rate for Payer: BCBS Trust/PPO	$103.55
Rate for Payer: BCBS Trust/PPO	$103.55
Rate for Payer: Cash Price	$88.80
Rate for Payer: Cash Price	$365.60
Rate for Payer: Cash Price	$365.60
Rate for Payer: Cash Price	$88.80
Rate for Payer: Priority Health Cigna Priority Health	$77.70
Rate for Payer: Priority Health Cigna Priority Health	$319.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$43.03
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$43.03
Rate for Payer: Priority Health Narrow Network	$43.03
Rate for Payer: Priority Health Narrow Network	$43.03
Rate for Payer: Priority Health SBD	$89.11
Rate for Payer: Priority Health SBD	$89.11
Rate for Payer: UMR Bronson Commercial	$210.22
Rate for Payer: UMR Bronson Commercial	$51.06

CHG US INTRAUTERINE FTL TFUJ/CORDOCNTS IMG S&I

Professional

Both

$183.00

Service Code	HCPCS 76941
Min. Negotiated Rate	$73.20
Max. Negotiated Rate	$180.28
Rate for Payer: Aetna Commercial	$138.84
Rate for Payer: BCBS Complete	$73.20
Rate for Payer: BCBS Trust/PPO	$145.81
Rate for Payer: Cash Price	$146.40
Rate for Payer: Cash Price	$146.40
Rate for Payer: Priority Health Cigna Priority Health	$128.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$82.98
Rate for Payer: Priority Health Narrow Network	$82.98
Rate for Payer: Priority Health SBD	$180.28
Rate for Payer: UMR Bronson Commercial	$84.18

CHG US LMTD JT/FCL EVAL NONVASC XTR STRUX R-T W/IMG

Professional

Both

$87.00

Service Code	HCPCS 76882
Min. Negotiated Rate	$14.34
Max. Negotiated Rate	$884.90
Rate for Payer: Aetna Commercial	$64.85
Rate for Payer: Aetna Commercial	$64.85
Rate for Payer: BCBS Complete	$26.40
Rate for Payer: BCBS Complete	$34.80
Rate for Payer: BCBS Trust/PPO	$884.90
Rate for Payer: BCBS Trust/PPO	$884.90
Rate for Payer: Cash Price	$69.60
Rate for Payer: Cash Price	$52.80
Rate for Payer: Cash Price	$52.80
Rate for Payer: Cash Price	$69.60
Rate for Payer: Priority Health Cigna Priority Health	$46.20
Rate for Payer: Priority Health Cigna Priority Health	$60.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$14.34
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$14.34
Rate for Payer: Priority Health Narrow Network	$14.34
Rate for Payer: Priority Health Narrow Network	$14.34
Rate for Payer: Priority Health SBD	$64.54
Rate for Payer: Priority Health SBD	$64.54
Rate for Payer: UMR Bronson Commercial	$40.02
Rate for Payer: UMR Bronson Commercial	$30.36

CHG US PELVIC NONOBSTETRIC IMAGE DCMTN LIMITED/F/U

Professional

Both

$221.00

Service Code	HCPCS 76857
Min. Negotiated Rate	$35.85
Max. Negotiated Rate	$839.47
Rate for Payer: Aetna Commercial	$55.35
Rate for Payer: BCBS Complete	$88.40
Rate for Payer: BCBS Trust/PPO	$839.47
Rate for Payer: Cash Price	$176.80
Rate for Payer: Cash Price	$176.80
Rate for Payer: Priority Health Cigna Priority Health	$154.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$35.85
Rate for Payer: Priority Health Narrow Network	$35.85
Rate for Payer: Priority Health SBD	$74.78
Rate for Payer: UMR Bronson Commercial	$101.66

CHG US PELVIC NONOBSTETRIC REAL-TIME IMAGE COMPLETE

Professional

Both

$295.00

Service Code	HCPCS 76856
Min. Negotiated Rate	$50.19
Max. Negotiated Rate	$764.98
Rate for Payer: Aetna Commercial	$125.54
Rate for Payer: BCBS Complete	$118.00
Rate for Payer: BCBS Trust/PPO	$764.98
Rate for Payer: Cash Price	$236.00
Rate for Payer: Cash Price	$236.00
Rate for Payer: Priority Health Cigna Priority Health	$206.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$50.19
Rate for Payer: Priority Health Narrow Network	$50.19
Rate for Payer: Priority Health SBD	$162.87
Rate for Payer: UMR Bronson Commercial	$135.70

CHG US PREGNANT UTERUS 14 WK TRANSABDL 1/1ST GESTAT

Professional

Both

$279.00

Service Code	HCPCS 76801
Min. Negotiated Rate	$71.70
Max. Negotiated Rate	$269.43
Rate for Payer: Aetna Commercial	$139.63
Rate for Payer: BCBS Complete	$111.60
Rate for Payer: BCBS Trust/PPO	$269.43
Rate for Payer: Cash Price	$223.20
Rate for Payer: Cash Price	$223.20
Rate for Payer: Priority Health Cigna Priority Health	$195.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$71.70
Rate for Payer: Priority Health Narrow Network	$71.70
Rate for Payer: Priority Health SBD	$181.31
Rate for Payer: UMR Bronson Commercial	$128.34

CHG US PREGNANT UTERUS LIMITED 1/> FETUSES

Professional

Both

$260.00

Service Code	HCPCS 76815
Min. Negotiated Rate	$47.64
Max. Negotiated Rate	$182.00
Rate for Payer: Aetna Commercial	$96.78
Rate for Payer: BCBS Complete	$104.00
Rate for Payer: BCBS Trust/PPO	$160.60
Rate for Payer: Cash Price	$208.00
Rate for Payer: Cash Price	$208.00
Rate for Payer: Priority Health Cigna Priority Health	$182.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$47.64
Rate for Payer: Priority Health Narrow Network	$47.64
Rate for Payer: Priority Health SBD	$125.48
Rate for Payer: UMR Bronson Commercial	$119.60

CHG US PREG UTERUS 14 WK TRANSABDL EACH GESTATION

Professional

Both

$140.00

Service Code	HCPCS 76802
Min. Negotiated Rate	$32.78
Max. Negotiated Rate	$304.83
Rate for Payer: Aetna Commercial	$73.01
Rate for Payer: BCBS Complete	$56.00
Rate for Payer: BCBS Trust/PPO	$304.83
Rate for Payer: Cash Price	$112.00
Rate for Payer: Cash Price	$112.00
Rate for Payer: Priority Health Cigna Priority Health	$98.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$32.78
Rate for Payer: Priority Health Narrow Network	$32.78
Rate for Payer: Priority Health SBD	$93.72
Rate for Payer: UMR Bronson Commercial	$64.40

CHG US PREG UTERUS > 1ST TRIMESTER ABDL EA GESTATIO

Professional

Both

$415.00

Service Code	HCPCS 76810
Min. Negotiated Rate	$64.02
Max. Negotiated Rate	$290.50
Rate for Payer: Aetna Commercial	$105.64
Rate for Payer: BCBS Complete	$166.00
Rate for Payer: BCBS Trust/PPO	$164.30
Rate for Payer: Cash Price	$332.00
Rate for Payer: Cash Price	$332.00
Rate for Payer: Priority Health Cigna Priority Health	$290.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$64.02
Rate for Payer: Priority Health Narrow Network	$64.02
Rate for Payer: Priority Health SBD	$135.72
Rate for Payer: UMR Bronson Commercial	$190.90

CHG US PREG UTERUS AFTER 1ST TRIMEST 1/1ST GESTATION

Professional

Both

$354.00

Service Code	HCPCS 76805
Min. Negotiated Rate	$72.21
Max. Negotiated Rate	$362.41
Rate for Payer: Aetna Commercial	$160.23
Rate for Payer: BCBS Complete	$141.60
Rate for Payer: BCBS Trust/PPO	$362.41
Rate for Payer: Cash Price	$283.20
Rate for Payer: Cash Price	$283.20
Rate for Payer: Priority Health Cigna Priority Health	$247.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$72.21
Rate for Payer: Priority Health Narrow Network	$72.21
Rate for Payer: Priority Health SBD	$208.96
Rate for Payer: UMR Bronson Commercial	$162.84

CHG US PREG UTERUS DETAIL FETAL ANAT EXAM EA GESTAT

Professional

Both

$339.00

Service Code	HCPCS 76812
Min. Negotiated Rate	$128.56
Max. Negotiated Rate	$294.49
Rate for Payer: Aetna Commercial	$228.84
Rate for Payer: BCBS Complete	$135.60
Rate for Payer: BCBS Trust/PPO	$136.83
Rate for Payer: Cash Price	$271.20
Rate for Payer: Cash Price	$271.20
Rate for Payer: Priority Health Cigna Priority Health	$237.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$128.56
Rate for Payer: Priority Health Narrow Network	$128.56
Rate for Payer: Priority Health SBD	$294.49
Rate for Payer: UMR Bronson Commercial	$155.94

CHG US PREG UTERUS REAL TIME F/U TRNSABDL PER FETUS

Professional

Both

$217.00

Service Code	HCPCS 76816
Min. Negotiated Rate	$61.45
Max. Negotiated Rate	$773.43
Rate for Payer: Aetna Commercial	$130.33
Rate for Payer: BCBS Complete	$86.80
Rate for Payer: BCBS Trust/PPO	$773.43
Rate for Payer: Cash Price	$173.60
Rate for Payer: Cash Price	$173.60
Rate for Payer: Priority Health Cigna Priority Health	$151.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$61.45
Rate for Payer: Priority Health Narrow Network	$61.45
Rate for Payer: Priority Health SBD	$168.50
Rate for Payer: UMR Bronson Commercial	$99.82

CHG US PREG UTERUS REAL TIME W/IMAGE DCMTN TRANSVAG

Professional

Both

$279.00

Service Code	HCPCS 76817
Min. Negotiated Rate	$54.80
Max. Negotiated Rate	$432.68
Rate for Payer: Aetna Commercial	$110.51
Rate for Payer: BCBS Complete	$111.60
Rate for Payer: BCBS Trust/PPO	$432.68
Rate for Payer: Cash Price	$223.20
Rate for Payer: Cash Price	$223.20
Rate for Payer: Priority Health Cigna Priority Health	$195.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$54.80
Rate for Payer: Priority Health Narrow Network	$54.80
Rate for Payer: Priority Health SBD	$142.90
Rate for Payer: UMR Bronson Commercial	$128.34

Know your out-of-pocket cost for care.

All Charges