Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

PR ADJT/REARRGMT SCALP/ARM/LEG 10.1-30.0 SQ CM

Facility

$1,450.00

Service Code	CPT 14021
Hospital Charge Code	14021
Hospital Revenue Code	960
Min. Negotiated Rate	$913.50
Max. Negotiated Rate	$1,305.00
Rate for Payer: Aetna Commercial	$1,232.50
Rate for Payer: Aetna New Business (MI Preferred)	$942.50
Rate for Payer: Cash Price	$1,160.00
Rate for Payer: Cofinity Commercial	$1,015.00
Rate for Payer: Cofinity Commercial	$1,247.00
Rate for Payer: Healthscope Commercial	$1,305.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1,232.50
Rate for Payer: PHP Commercial	$1,232.50
Rate for Payer: Priority Health Cigna Priority Health	$1,015.00
Rate for Payer: Priority Health SBD	$913.50

PR ADJT/REARRGMT SCALP/ARM/LEG 10.1-30.0 SQ CM

Professional

Both

$1,450.00

Service Code	HCPCS 14021
Min. Negotiated Rate	$206.12
Max. Negotiated Rate	$1,015.00
Rate for Payer: Aetna Commercial	$753.63
Rate for Payer: BCBS Complete	$475.70
Rate for Payer: BCBS Trust/PPO	$206.12
Rate for Payer: Cash Price	$1,160.00
Rate for Payer: Cash Price	$1,160.00
Rate for Payer: Mclaren Medicaid	$453.05
Rate for Payer: Meridian Medicaid	$475.70
Rate for Payer: Priority Health Choice Medicaid	$453.05
Rate for Payer: Priority Health Cigna Priority Health	$1,015.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$866.05
Rate for Payer: Priority Health Narrow Network	$866.05
Rate for Payer: Priority Health SBD	$866.05

PR ADJT/REARRGMT SCALP/ARM/LEG 10.1-30.0 SQ CM

Facility

$1,450.00

Service Code	CPT 14021
Hospital Charge Code	14021
Hospital Revenue Code	960
Min. Negotiated Rate	$696.47
Max. Negotiated Rate	$5,175.07
Rate for Payer: Aetna Commercial	$1,232.50
Rate for Payer: Aetna Medicare	$1,687.55
Rate for Payer: Aetna New Business (MI Preferred)	$942.50
Rate for Payer: Allen County Amish Medical Aid Commercial	$2,028.30
Rate for Payer: Amish Plain Church Group Commercial	$2,028.30
Rate for Payer: BCBS Complete	$932.04
Rate for Payer: BCBS MAPPO	$1,622.64
Rate for Payer: BCBS Trust/PPO	$796.18
Rate for Payer: BCN Medicare Advantage	$1,622.64
Rate for Payer: Cash Price	$1,160.00
Rate for Payer: Cash Price	$1,160.00
Rate for Payer: Cofinity Commercial	$1,015.00
Rate for Payer: Cofinity Commercial	$1,247.00
Rate for Payer: Health Alliance Plan Medicare Advantage	$1,622.64
Rate for Payer: Healthscope Commercial	$1,305.00
Rate for Payer: Mclaren Medicaid	$887.58
Rate for Payer: Mclaren Medicare	$1,622.64
Rate for Payer: Meridian Medicaid	$932.04
Rate for Payer: Meridian Wellcare - Medicare Advantage	$1,703.77
Rate for Payer: MI Amish Medical Board Commercial	$1,866.04
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1,232.50
Rate for Payer: PACE Medicare	$1,541.51
Rate for Payer: PACE SWMI	$1,622.64
Rate for Payer: PHP Commercial	$1,232.50
Rate for Payer: PHP Medicare Advantage	$1,622.64
Rate for Payer: Priority Health Choice Medicaid	$887.58
Rate for Payer: Priority Health Cigna Priority Health	$1,015.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$5,175.07
Rate for Payer: Priority Health Medicare	$1,622.64
Rate for Payer: Priority Health Narrow Network	$4,140.06
Rate for Payer: Priority Health SBD	$913.50
Rate for Payer: Railroad Medicare Medicare	$1,622.64
Rate for Payer: UHC All Payor (Choice/PPO)	$766.12
Rate for Payer: UHC Dual Complete DSNP	$1,622.64
Rate for Payer: UHC Exchange	$696.47
Rate for Payer: UHC Medicare Advantage	$1,671.32
Rate for Payer: VA VA	$1,622.64

PR ADJT/REARRGMT SCALP/ARM/LEG 10.1-30.0 SQ CM

Professional

Both

$1,450.00

Service Code	HCPCS 14021
Hospital Charge Code	14021
Min. Negotiated Rate	$206.12
Max. Negotiated Rate	$1,015.00
Rate for Payer: Aetna Commercial	$753.63
Rate for Payer: BCBS Complete	$475.70
Rate for Payer: BCBS Trust/PPO	$206.12
Rate for Payer: Cash Price	$1,160.00
Rate for Payer: Cash Price	$1,160.00
Rate for Payer: Mclaren Medicaid	$453.05
Rate for Payer: Meridian Medicaid	$475.70
Rate for Payer: Priority Health Choice Medicaid	$453.05
Rate for Payer: Priority Health Cigna Priority Health	$1,015.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$866.05
Rate for Payer: Priority Health Narrow Network	$866.05
Rate for Payer: Priority Health SBD	$866.05

PR ADJT TIS REARGMT EYE/NOSE/EAR/LIP 10.1-30.0 SQCM

Professional

Both

$2,191.00

Service Code	HCPCS 14061
Min. Negotiated Rate	$138.90
Max. Negotiated Rate	$1,533.70
Rate for Payer: Aetna Commercial	$870.72
Rate for Payer: BCBS Complete	$548.61
Rate for Payer: BCBS Trust/PPO	$138.90
Rate for Payer: Cash Price	$1,752.80
Rate for Payer: Cash Price	$1,752.80
Rate for Payer: Mclaren Medicaid	$522.49
Rate for Payer: Meridian Medicaid	$548.61
Rate for Payer: Priority Health Choice Medicaid	$522.49
Rate for Payer: Priority Health Cigna Priority Health	$1,533.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$998.41
Rate for Payer: Priority Health Narrow Network	$998.41
Rate for Payer: Priority Health SBD	$998.41

PR ADJT TIS TRNSFR/REARGMT DEFEC EA ADDL 30 SQCM

Professional

Both

$443.00

Service Code	HCPCS 14302
Min. Negotiated Rate	$136.32
Max. Negotiated Rate	$310.10
Rate for Payer: Aetna Commercial	$235.75
Rate for Payer: BCBS Complete	$143.14
Rate for Payer: BCBS Trust/PPO	$138.90
Rate for Payer: Cash Price	$354.40
Rate for Payer: Cash Price	$354.40
Rate for Payer: Mclaren Medicaid	$136.32
Rate for Payer: Meridian Medicaid	$143.14
Rate for Payer: Priority Health Choice Medicaid	$136.32
Rate for Payer: Priority Health Cigna Priority Health	$310.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$263.07
Rate for Payer: Priority Health Narrow Network	$263.07
Rate for Payer: Priority Health SBD	$263.07

PR ADJT TIS TRNSFR/REARGMT SCALP/ARM/LEG 10 SQ CM/<

Professional

Both

$1,146.00

Service Code	HCPCS 14020
Min. Negotiated Rate	$48.14
Max. Negotiated Rate	$802.20
Rate for Payer: Aetna Commercial	$598.90
Rate for Payer: BCBS Complete	$381.55
Rate for Payer: BCBS Trust/PPO	$48.14
Rate for Payer: Cash Price	$916.80
Rate for Payer: Cash Price	$916.80
Rate for Payer: Mclaren Medicaid	$363.38
Rate for Payer: Meridian Medicaid	$381.55
Rate for Payer: Priority Health Choice Medicaid	$363.38
Rate for Payer: Priority Health Cigna Priority Health	$802.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$692.60
Rate for Payer: Priority Health Narrow Network	$692.60
Rate for Payer: Priority Health SBD	$692.60

PR ADJT TIS TRNSFR/REARRGMT E/N/E/L DFCT 10 SQ CM/<

Professional

Both

$2,026.00

Service Code	HCPCS 14060
Min. Negotiated Rate	$206.12
Max. Negotiated Rate	$1,418.20
Rate for Payer: Aetna Commercial	$705.60
Rate for Payer: BCBS Complete	$446.19
Rate for Payer: BCBS Trust/PPO	$206.12
Rate for Payer: Cash Price	$1,620.80
Rate for Payer: Cash Price	$1,620.80
Rate for Payer: Mclaren Medicaid	$424.94
Rate for Payer: Meridian Medicaid	$446.19
Rate for Payer: Priority Health Choice Medicaid	$424.94
Rate for Payer: Priority Health Cigna Priority Health	$1,418.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$812.62
Rate for Payer: Priority Health Narrow Network	$812.62
Rate for Payer: Priority Health SBD	$812.62

PR ADJT TIS TRNS/REARGMT F/C/C/M/N/A/G/H/F 10SQCM/<

Facility

$1,274.00

Service Code	CPT 14040
Hospital Charge Code	14040
Hospital Revenue Code	960
Min. Negotiated Rate	$802.62
Max. Negotiated Rate	$1,146.60
Rate for Payer: Aetna Commercial	$1,082.90
Rate for Payer: Aetna New Business (MI Preferred)	$828.10
Rate for Payer: Cash Price	$1,019.20
Rate for Payer: Cofinity Commercial	$1,095.64
Rate for Payer: Cofinity Commercial	$891.80
Rate for Payer: Healthscope Commercial	$1,146.60
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1,082.90
Rate for Payer: PHP Commercial	$1,082.90
Rate for Payer: Priority Health Cigna Priority Health	$891.80
Rate for Payer: Priority Health SBD	$802.62

PR ADJT TIS TRNS/REARGMT F/C/C/M/N/A/G/H/F 10SQCM/<

Professional

Both

$1,274.00

Service Code	HCPCS 14040
Hospital Charge Code	14040
Min. Negotiated Rate	$344.90
Max. Negotiated Rate	$891.80
Rate for Payer: Aetna Commercial	$663.21
Rate for Payer: BCBS Complete	$418.90
Rate for Payer: BCBS Trust/PPO	$344.90
Rate for Payer: Cash Price	$1,019.20
Rate for Payer: Cash Price	$1,019.20
Rate for Payer: Mclaren Medicaid	$398.95
Rate for Payer: Meridian Medicaid	$418.90
Rate for Payer: Priority Health Choice Medicaid	$398.95
Rate for Payer: Priority Health Cigna Priority Health	$891.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$762.07
Rate for Payer: Priority Health Narrow Network	$762.07
Rate for Payer: Priority Health SBD	$762.07

PR ADJT TIS TRNS/REARGMT F/C/C/M/N/A/G/H/F 10SQCM/<

Professional

Both

$1,274.00

Service Code	HCPCS 14040
Min. Negotiated Rate	$344.90
Max. Negotiated Rate	$891.80
Rate for Payer: Aetna Commercial	$663.21
Rate for Payer: BCBS Complete	$418.90
Rate for Payer: BCBS Trust/PPO	$344.90
Rate for Payer: Cash Price	$1,019.20
Rate for Payer: Cash Price	$1,019.20
Rate for Payer: Mclaren Medicaid	$398.95
Rate for Payer: Meridian Medicaid	$418.90
Rate for Payer: Priority Health Choice Medicaid	$398.95
Rate for Payer: Priority Health Cigna Priority Health	$891.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$762.07
Rate for Payer: Priority Health Narrow Network	$762.07
Rate for Payer: Priority Health SBD	$762.07

PR ADJT TIS TRNS/REARGMT F/C/C/M/N/A/G/H/F 10SQCM/<

Facility

$1,274.00

Service Code	CPT 14040
Hospital Charge Code	14040
Hospital Revenue Code	960
Min. Negotiated Rate	$613.30
Max. Negotiated Rate	$5,175.07
Rate for Payer: Aetna Commercial	$1,082.90
Rate for Payer: Aetna Medicare	$1,687.55
Rate for Payer: Aetna New Business (MI Preferred)	$828.10
Rate for Payer: Allen County Amish Medical Aid Commercial	$2,028.30
Rate for Payer: Amish Plain Church Group Commercial	$2,028.30
Rate for Payer: BCBS Complete	$932.04
Rate for Payer: BCBS MAPPO	$1,622.64
Rate for Payer: BCBS Trust/PPO	$1,151.49
Rate for Payer: BCN Medicare Advantage	$1,622.64
Rate for Payer: Cash Price	$1,019.20
Rate for Payer: Cash Price	$1,019.20
Rate for Payer: Cofinity Commercial	$1,095.64
Rate for Payer: Cofinity Commercial	$891.80
Rate for Payer: Health Alliance Plan Medicare Advantage	$1,622.64
Rate for Payer: Healthscope Commercial	$1,146.60
Rate for Payer: Mclaren Medicaid	$887.58
Rate for Payer: Mclaren Medicare	$1,622.64
Rate for Payer: Meridian Medicaid	$932.04
Rate for Payer: Meridian Wellcare - Medicare Advantage	$1,703.77
Rate for Payer: MI Amish Medical Board Commercial	$1,866.04
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1,082.90
Rate for Payer: PACE Medicare	$1,541.51
Rate for Payer: PACE SWMI	$1,622.64
Rate for Payer: PHP Commercial	$1,082.90
Rate for Payer: PHP Medicare Advantage	$1,622.64
Rate for Payer: Priority Health Choice Medicaid	$887.58
Rate for Payer: Priority Health Cigna Priority Health	$891.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$5,175.07
Rate for Payer: Priority Health Medicare	$1,622.64
Rate for Payer: Priority Health Narrow Network	$4,140.06
Rate for Payer: Priority Health SBD	$802.62
Rate for Payer: Railroad Medicare Medicare	$1,622.64
Rate for Payer: UHC All Payor (Choice/PPO)	$674.63
Rate for Payer: UHC Dual Complete DSNP	$1,622.64
Rate for Payer: UHC Exchange	$613.30
Rate for Payer: UHC Medicare Advantage	$1,671.32
Rate for Payer: VA VA	$1,622.64

PR ADJUSTMENT GASTRIC BAND

Professional

Both

$113.00

Service Code	HCPCS S2083
Min. Negotiated Rate	$45.20
Max. Negotiated Rate	$486.56
Rate for Payer: Aetna Commercial	$67.62
Rate for Payer: BCBS Complete	$45.20
Rate for Payer: BCBS Trust/PPO	$486.56
Rate for Payer: Cash Price	$90.40
Rate for Payer: Cash Price	$90.40
Rate for Payer: Priority Health Cigna Priority Health	$79.10

PR ADJUSTMENT/REVJ XTRNL FIXATION SYSTEM REQ ANES

Professional

Both

$1,005.00

Service Code	HCPCS 20693
Min. Negotiated Rate	$289.25
Max. Negotiated Rate	$3,350.93
Rate for Payer: Aetna Commercial	$588.13
Rate for Payer: BCBS Complete	$303.71
Rate for Payer: BCBS Trust/PPO	$3,350.93
Rate for Payer: Cash Price	$804.00
Rate for Payer: Cash Price	$804.00
Rate for Payer: Mclaren Medicaid	$289.25
Rate for Payer: Meridian Medicaid	$303.71
Rate for Payer: Priority Health Choice Medicaid	$289.25
Rate for Payer: Priority Health Cigna Priority Health	$703.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$679.16
Rate for Payer: Priority Health Narrow Network	$679.16
Rate for Payer: Priority Health SBD	$679.16

PR ADMIN HEPATITIS B VACCINE

Professional

Both

$29.00

Service Code	HCPCS G0010
Min. Negotiated Rate	$10.00
Max. Negotiated Rate	$1,469.20
Rate for Payer: Aetna Commercial	$10.00
Rate for Payer: BCBS Complete	$11.60
Rate for Payer: BCBS Trust/PPO	$1,469.20
Rate for Payer: Cash Price	$23.20
Rate for Payer: Cash Price	$23.20
Rate for Payer: Priority Health Cigna Priority Health	$20.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$39.97
Rate for Payer: Priority Health Narrow Network	$39.97
Rate for Payer: Priority Health SBD	$39.97

PR ADMIN INFLUENZA VIRUS VAC

Professional

Both

$32.00

Service Code	HCPCS G0008
Min. Negotiated Rate	$10.00
Max. Negotiated Rate	$4,626.85
Rate for Payer: Aetna Commercial	$10.00
Rate for Payer: BCBS Complete	$12.80
Rate for Payer: BCBS Trust/PPO	$4,626.85
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	$39.97
Rate for Payer: Priority Health Narrow Network	$39.97
Rate for Payer: Priority Health SBD	$39.97

PR ADMIN PNEUMOCOCCAL VACCINE

Professional

Both

$32.00

Service Code	HCPCS G0009
Min. Negotiated Rate	$10.00
Max. Negotiated Rate	$1,331.32
Rate for Payer: Aetna Commercial	$10.00
Rate for Payer: BCBS Complete	$12.80
Rate for Payer: BCBS Trust/PPO	$1,331.32
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	$39.97
Rate for Payer: Priority Health Narrow Network	$39.97
Rate for Payer: Priority Health SBD	$39.97

PR ADMN RSV MONOC ANTB SEASONAL DOS IM CNSL PHY/QHP

Professional

Both

$83.04

Service Code	HCPCS 96380
Min. Negotiated Rate	$12.00
Max. Negotiated Rate	$58.13
Rate for Payer: Aetna Commercial	$12.00
Rate for Payer: BCBS Complete	$33.22
Rate for Payer: Cash Price	$66.43
Rate for Payer: Cash Price	$66.43
Rate for Payer: Priority Health Cigna Priority Health	$58.13

PR ADMN RSV MONOCLONAL ANTB SEASONAL DOSE IM NJX

Professional

Both

$83.04

Service Code	HCPCS 96381
Min. Negotiated Rate	$12.00
Max. Negotiated Rate	$58.13
Rate for Payer: Aetna Commercial	$12.00
Rate for Payer: BCBS Complete	$33.22
Rate for Payer: Cash Price	$66.43
Rate for Payer: Cash Price	$66.43
Rate for Payer: Priority Health Cigna Priority Health	$58.13

PR ADRENALECTOMY EXPL W/EXC RETROPERTINEAL TUMOR

Professional

Both

$4,350.00

Service Code	HCPCS 60545
Min. Negotiated Rate	$341.28
Max. Negotiated Rate	$3,045.00
Rate for Payer: Aetna Commercial	$1,609.79
Rate for Payer: BCBS Complete	$838.91
Rate for Payer: BCBS Trust/PPO	$341.28
Rate for Payer: Cash Price	$3,480.00
Rate for Payer: Cash Price	$3,480.00
Rate for Payer: Mclaren Medicaid	$798.96
Rate for Payer: Meridian Medicaid	$838.91
Rate for Payer: Priority Health Choice Medicaid	$798.96
Rate for Payer: Priority Health Cigna Priority Health	$3,045.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,759.61
Rate for Payer: Priority Health Narrow Network	$1,759.61
Rate for Payer: Priority Health SBD	$1,759.61

PR ADRENALECTOMY W/EXPL W/WO BX ABDL/LMBR/DRSAL SPX

Professional

Both

$3,303.00

Service Code	HCPCS 60540
Min. Negotiated Rate	$432.15
Max. Negotiated Rate	$2,312.10
Rate for Payer: Aetna Commercial	$1,390.93
Rate for Payer: BCBS Complete	$723.95
Rate for Payer: BCBS Trust/PPO	$432.15
Rate for Payer: Cash Price	$2,642.40
Rate for Payer: Cash Price	$2,642.40
Rate for Payer: Mclaren Medicaid	$689.48
Rate for Payer: Meridian Medicaid	$723.95
Rate for Payer: Priority Health Choice Medicaid	$689.48
Rate for Payer: Priority Health Cigna Priority Health	$2,312.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,517.36
Rate for Payer: Priority Health Narrow Network	$1,517.36
Rate for Payer: Priority Health SBD	$1,517.36

PR ADRENALIN EPINEPHRINE INJECT

Professional

Both

$5.00

Service Code	HCPCS J0171
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$3.50
Rate for Payer: Aetna Commercial	$0.77
Rate for Payer: BCBS Complete	$2.00
Rate for Payer: BCBS Trust/PPO	$0.15
Rate for Payer: Cash Price	$4.00
Rate for Payer: Cash Price	$4.00
Rate for Payer: Priority Health Cigna Priority Health	$3.50

PR ADVANCE CARE PLANNING EA ADDL 30 MINS

Professional

Both

$80.00

Service Code	HCPCS 99498
Min. Negotiated Rate	$44.94
Max. Negotiated Rate	$533.05
Rate for Payer: Aetna Commercial	$72.67
Rate for Payer: BCBS Complete	$47.19
Rate for Payer: BCBS Trust/PPO	$533.05
Rate for Payer: Cash Price	$64.00
Rate for Payer: Cash Price	$64.00
Rate for Payer: Mclaren Medicaid	$44.94
Rate for Payer: Meridian Medicaid	$47.19
Rate for Payer: Priority Health Choice Medicaid	$44.94
Rate for Payer: Priority Health Cigna Priority Health	$56.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$92.17
Rate for Payer: Priority Health Narrow Network	$92.17
Rate for Payer: Priority Health SBD	$92.17

PR ADVANCE CARE PLANNING FIRST 30 MINS

Professional

Both

$101.00

Service Code	HCPCS 99497
Min. Negotiated Rate	$47.71
Max. Negotiated Rate	$569.51
Rate for Payer: Aetna Commercial	$77.18
Rate for Payer: BCBS Complete	$50.10
Rate for Payer: BCBS Trust/PPO	$569.51
Rate for Payer: Cash Price	$80.80
Rate for Payer: Cash Price	$80.80
Rate for Payer: Mclaren Medicaid	$47.71
Rate for Payer: Meridian Medicaid	$50.10
Rate for Payer: Priority Health Choice Medicaid	$47.71
Rate for Payer: Priority Health Cigna Priority Health	$70.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$97.42
Rate for Payer: Priority Health Narrow Network	$97.42
Rate for Payer: Priority Health SBD	$97.42

PR AEP HEARING STATUS DETER BROADBAND STIMULI I&R

Professional

Both

$158.00

Service Code	HCPCS 92651
Min. Negotiated Rate	$63.20
Max. Negotiated Rate	$3,831.23
Rate for Payer: Aetna Commercial	$96.89
Rate for Payer: BCBS Complete	$63.20
Rate for Payer: BCBS Trust/PPO	$3,831.23
Rate for Payer: Cash Price	$126.40
Rate for Payer: Cash Price	$126.40
Rate for Payer: Priority Health Cigna Priority Health	$110.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$113.63
Rate for Payer: Priority Health Narrow Network	$113.63
Rate for Payer: Priority Health SBD	$113.63

Know your out-of-pocket cost for care.

All Charges