Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

PR DSTRJ NEURLYTIC TRIGEM NRV 2/3 DIV RADIO MONITOR

Professional

Both

$1,188.00

Service Code	HCPCS 64610
Min. Negotiated Rate	$309.49
Max. Negotiated Rate	$831.60
Rate for Payer: Aetna Commercial	$624.37
Rate for Payer: BCBS Complete	$324.96
Rate for Payer: BCBS Trust/PPO	$309.58
Rate for Payer: Cash Price	$950.40
Rate for Payer: Cash Price	$950.40
Rate for Payer: Mclaren Medicaid	$309.49
Rate for Payer: Meridian Medicaid	$324.96
Rate for Payer: Priority Health Choice Medicaid	$309.49
Rate for Payer: Priority Health Cigna Priority Health	$831.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$819.90
Rate for Payer: Priority Health Narrow Network	$819.90
Rate for Payer: Priority Health SBD	$819.90

PR DSTRJ NEUROLYTIC AGENT INTERCOSTAL NERVE

Professional

Both

$757.00

Service Code	HCPCS 64620
Min. Negotiated Rate	$113.32
Max. Negotiated Rate	$1,271.09
Rate for Payer: Aetna Commercial	$225.82
Rate for Payer: BCBS Complete	$118.99
Rate for Payer: BCBS Trust/PPO	$1,271.09
Rate for Payer: Cash Price	$605.60
Rate for Payer: Cash Price	$605.60
Rate for Payer: Mclaren Medicaid	$113.32
Rate for Payer: Meridian Medicaid	$118.99
Rate for Payer: Priority Health Choice Medicaid	$113.32
Rate for Payer: Priority Health Cigna Priority Health	$529.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$297.84
Rate for Payer: Priority Health Narrow Network	$297.84
Rate for Payer: Priority Health SBD	$297.84

PR DSTRJ NEUROLYTIC AGENT OTHER PERIPHERAL NERVE

Facility

$596.00

Service Code	CPT 64640
Hospital Charge Code	64640
Min. Negotiated Rate	$64.04
Max. Negotiated Rate	$2,563.14
Rate for Payer: Aetna Commercial	$506.60
Rate for Payer: Aetna Medicare	$843.47
Rate for Payer: Aetna New Business (MI Preferred)	$387.40
Rate for Payer: Allen County Amish Medical Aid Commercial	$1,013.79
Rate for Payer: Amish Plain Church Group Commercial	$1,013.79
Rate for Payer: BCBS Complete	$465.86
Rate for Payer: BCBS MAPPO	$811.03
Rate for Payer: BCBS Trust/PPO	$64.04
Rate for Payer: BCN Medicare Advantage	$811.03
Rate for Payer: Cash Price	$476.80
Rate for Payer: Cash Price	$476.80
Rate for Payer: Cofinity Commercial	$512.56
Rate for Payer: Cofinity Commercial	$417.20
Rate for Payer: Health Alliance Plan Medicare Advantage	$811.03
Rate for Payer: Healthscope Commercial	$536.40
Rate for Payer: Mclaren Medicaid	$443.63
Rate for Payer: Mclaren Medicare	$811.03
Rate for Payer: Meridian Medicaid	$465.86
Rate for Payer: Meridian Wellcare - Medicare Advantage	$851.58
Rate for Payer: MI Amish Medical Board Commercial	$932.68
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$506.60
Rate for Payer: PACE Medicare	$770.48
Rate for Payer: PACE SWMI	$811.03
Rate for Payer: PHP Commercial	$506.60
Rate for Payer: PHP Medicare Advantage	$811.03
Rate for Payer: Priority Health Choice Medicaid	$443.63
Rate for Payer: Priority Health Cigna Priority Health	$417.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,563.14
Rate for Payer: Priority Health Medicare	$811.03
Rate for Payer: Priority Health Narrow Network	$2,050.51
Rate for Payer: Priority Health SBD	$375.48
Rate for Payer: Railroad Medicare Medicare	$811.03
Rate for Payer: UHC All Payor (Choice/PPO)	$128.23
Rate for Payer: UHC Dual Complete DSNP	$811.03
Rate for Payer: UHC Exchange	$116.57
Rate for Payer: UHC Medicare Advantage	$835.36
Rate for Payer: VA VA	$811.03

PR DSTRJ NEUROLYTIC AGENT OTHER PERIPHERAL NERVE

Facility

$596.00

Service Code	CPT 64640
Hospital Charge Code	64640
Min. Negotiated Rate	$375.48
Max. Negotiated Rate	$536.40
Rate for Payer: Aetna Commercial	$506.60
Rate for Payer: Aetna New Business (MI Preferred)	$387.40
Rate for Payer: Cash Price	$476.80
Rate for Payer: Cofinity Commercial	$417.20
Rate for Payer: Cofinity Commercial	$512.56
Rate for Payer: Healthscope Commercial	$536.40
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$506.60
Rate for Payer: PHP Commercial	$506.60
Rate for Payer: Priority Health Cigna Priority Health	$417.20
Rate for Payer: Priority Health SBD	$375.48

PR DSTRJ NEUROLYTIC AGENT OTHER PERIPHERAL NERVE

Professional

Both

$596.00

Service Code	HCPCS 64640
Min. Negotiated Rate	$75.83
Max. Negotiated Rate	$720.07
Rate for Payer: Aetna Commercial	$151.56
Rate for Payer: BCBS Complete	$79.62
Rate for Payer: BCBS Trust/PPO	$720.07
Rate for Payer: Cash Price	$476.80
Rate for Payer: Cash Price	$476.80
Rate for Payer: Mclaren Medicaid	$75.83
Rate for Payer: Meridian Medicaid	$79.62
Rate for Payer: Priority Health Choice Medicaid	$75.83
Rate for Payer: Priority Health Cigna Priority Health	$417.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$198.19
Rate for Payer: Priority Health Narrow Network	$198.19
Rate for Payer: Priority Health SBD	$198.19

PR DSTRJ NEUROLYTIC AGENT OTHER PERIPHERAL NERVE

Professional

Both

$596.00

Service Code	HCPCS 64640
Hospital Charge Code	64640
Min. Negotiated Rate	$75.83
Max. Negotiated Rate	$720.07
Rate for Payer: Aetna Commercial	$151.56
Rate for Payer: BCBS Complete	$79.62
Rate for Payer: BCBS Trust/PPO	$720.07
Rate for Payer: Cash Price	$476.80
Rate for Payer: Cash Price	$476.80
Rate for Payer: Mclaren Medicaid	$75.83
Rate for Payer: Meridian Medicaid	$79.62
Rate for Payer: Priority Health Choice Medicaid	$75.83
Rate for Payer: Priority Health Cigna Priority Health	$417.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$198.19
Rate for Payer: Priority Health Narrow Network	$198.19
Rate for Payer: Priority Health SBD	$198.19

PR DSTRJ NEUROLYTIC W/WO RAD MONITOR CELIAC PLEXUS

Professional

Both

$673.00

Service Code	HCPCS 64680
Min. Negotiated Rate	$102.03
Max. Negotiated Rate	$1,009.58
Rate for Payer: Aetna Commercial	$206.19
Rate for Payer: BCBS Complete	$107.13
Rate for Payer: BCBS Trust/PPO	$1,009.58
Rate for Payer: Cash Price	$538.40
Rate for Payer: Cash Price	$538.40
Rate for Payer: Mclaren Medicaid	$102.03
Rate for Payer: Meridian Medicaid	$107.13
Rate for Payer: Priority Health Choice Medicaid	$102.03
Rate for Payer: Priority Health Cigna Priority Health	$471.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$271.22
Rate for Payer: Priority Health Narrow Network	$271.22
Rate for Payer: Priority Health SBD	$271.22

PR DSTRJ NULYT W/WORAD MNTR SUPRIOR HYPOGSTR PLEXUS

Professional

Both

$895.00

Service Code	HCPCS 64681
Min. Negotiated Rate	$138.88
Max. Negotiated Rate	$1,572.75
Rate for Payer: Aetna Commercial	$288.28
Rate for Payer: BCBS Complete	$145.82
Rate for Payer: BCBS Trust/PPO	$1,572.75
Rate for Payer: Cash Price	$716.00
Rate for Payer: Cash Price	$716.00
Rate for Payer: Mclaren Medicaid	$138.88
Rate for Payer: Meridian Medicaid	$145.82
Rate for Payer: Priority Health Choice Medicaid	$138.88
Rate for Payer: Priority Health Cigna Priority Health	$626.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$373.15
Rate for Payer: Priority Health Narrow Network	$373.15
Rate for Payer: Priority Health SBD	$373.15

PR DSTRJ TRIGEMINAL NRV SUPRAORB INFRAORB BRANCH

Professional

Both

$881.00

Service Code	HCPCS 64600
Min. Negotiated Rate	$152.30
Max. Negotiated Rate	$3,486.25
Rate for Payer: Aetna Commercial	$292.11
Rate for Payer: BCBS Complete	$159.92
Rate for Payer: BCBS Trust/PPO	$3,486.25
Rate for Payer: Cash Price	$704.80
Rate for Payer: Cash Price	$704.80
Rate for Payer: Mclaren Medicaid	$152.30
Rate for Payer: Meridian Medicaid	$159.92
Rate for Payer: Priority Health Choice Medicaid	$152.30
Rate for Payer: Priority Health Cigna Priority Health	$616.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$391.26
Rate for Payer: Priority Health Narrow Network	$391.26
Rate for Payer: Priority Health SBD	$391.26

PR DSTR NROLYTC AGNT PARVERTEB FCT ADDL CRVCL/THORA

Professional

Both

$168.00

Service Code	HCPCS 64634
Min. Negotiated Rate	$42.39
Max. Negotiated Rate	$667.24
Rate for Payer: Aetna Commercial	$87.55
Rate for Payer: BCBS Complete	$44.51
Rate for Payer: BCBS Trust/PPO	$667.24
Rate for Payer: Cash Price	$134.40
Rate for Payer: Cash Price	$134.40
Rate for Payer: Mclaren Medicaid	$42.39
Rate for Payer: Meridian Medicaid	$44.51
Rate for Payer: Priority Health Choice Medicaid	$42.39
Rate for Payer: Priority Health Cigna Priority Health	$117.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$111.55
Rate for Payer: Priority Health Narrow Network	$111.55
Rate for Payer: Priority Health SBD	$111.55

PR DSTR NROLYTC AGNT PARVERTEB FCT ADDL LMBR/SACRAL

Professional

Both

$329.00

Service Code	HCPCS 64636
Min. Negotiated Rate	$37.06
Max. Negotiated Rate	$654.04
Rate for Payer: Aetna Commercial	$76.93
Rate for Payer: BCBS Complete	$38.91
Rate for Payer: BCBS Trust/PPO	$654.04
Rate for Payer: Cash Price	$263.20
Rate for Payer: Cash Price	$263.20
Rate for Payer: Mclaren Medicaid	$37.06
Rate for Payer: Meridian Medicaid	$38.91
Rate for Payer: Priority Health Choice Medicaid	$37.06
Rate for Payer: Priority Health Cigna Priority Health	$230.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$98.52
Rate for Payer: Priority Health Narrow Network	$98.52
Rate for Payer: Priority Health SBD	$98.52

PR DSTR NROLYTC AGNT PARVERTEB FCT SNGL CRVCL/THORA

Facility

$610.00

Service Code	CPT 64633
Hospital Charge Code	64633
Min. Negotiated Rate	$384.30
Max. Negotiated Rate	$549.00
Rate for Payer: Aetna Commercial	$518.50
Rate for Payer: Aetna New Business (MI Preferred)	$396.50
Rate for Payer: Cash Price	$488.00
Rate for Payer: Cofinity Commercial	$427.00
Rate for Payer: Cofinity Commercial	$524.60
Rate for Payer: Healthscope Commercial	$549.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$518.50
Rate for Payer: PHP Commercial	$518.50
Rate for Payer: Priority Health Cigna Priority Health	$427.00
Rate for Payer: Priority Health SBD	$384.30

PR DSTR NROLYTC AGNT PARVERTEB FCT SNGL CRVCL/THORA

Professional

Both

$610.00

Service Code	HCPCS 64633
Min. Negotiated Rate	$122.26
Max. Negotiated Rate	$427.00
Rate for Payer: Aetna Commercial	$287.73
Rate for Payer: BCBS Complete	$128.37
Rate for Payer: BCBS Trust/PPO	$254.64
Rate for Payer: Cash Price	$488.00
Rate for Payer: Cash Price	$488.00
Rate for Payer: Mclaren Medicaid	$122.26
Rate for Payer: Meridian Medicaid	$128.37
Rate for Payer: Priority Health Choice Medicaid	$122.26
Rate for Payer: Priority Health Cigna Priority Health	$427.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$319.91
Rate for Payer: Priority Health Narrow Network	$319.91
Rate for Payer: Priority Health SBD	$319.91

PR DSTR NROLYTC AGNT PARVERTEB FCT SNGL CRVCL/THORA

Professional

Both

$610.00

Service Code	HCPCS 64633
Hospital Charge Code	64633
Min. Negotiated Rate	$122.26
Max. Negotiated Rate	$427.00
Rate for Payer: Aetna Commercial	$287.73
Rate for Payer: BCBS Complete	$128.37
Rate for Payer: BCBS Trust/PPO	$254.64
Rate for Payer: Cash Price	$488.00
Rate for Payer: Cash Price	$488.00
Rate for Payer: Mclaren Medicaid	$122.26
Rate for Payer: Meridian Medicaid	$128.37
Rate for Payer: Priority Health Choice Medicaid	$122.26
Rate for Payer: Priority Health Cigna Priority Health	$427.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$319.91
Rate for Payer: Priority Health Narrow Network	$319.91
Rate for Payer: Priority Health SBD	$319.91

PR DSTR NROLYTC AGNT PARVERTEB FCT SNGL CRVCL/THORA

Facility

$610.00

Service Code	CPT 64633
Hospital Charge Code	64633
Min. Negotiated Rate	$187.95
Max. Negotiated Rate	$5,467.25
Rate for Payer: Aetna Commercial	$518.50
Rate for Payer: Aetna Medicare	$1,786.71
Rate for Payer: Aetna New Business (MI Preferred)	$396.50
Rate for Payer: Allen County Amish Medical Aid Commercial	$2,147.49
Rate for Payer: Amish Plain Church Group Commercial	$2,147.49
Rate for Payer: BCBS Complete	$986.81
Rate for Payer: BCBS MAPPO	$1,717.99
Rate for Payer: BCBS Trust/PPO	$767.90
Rate for Payer: BCN Medicare Advantage	$1,717.99
Rate for Payer: Cash Price	$488.00
Rate for Payer: Cash Price	$488.00
Rate for Payer: Cofinity Commercial	$524.60
Rate for Payer: Cofinity Commercial	$427.00
Rate for Payer: Health Alliance Plan Medicare Advantage	$1,717.99
Rate for Payer: Healthscope Commercial	$549.00
Rate for Payer: Mclaren Medicaid	$939.74
Rate for Payer: Mclaren Medicare	$1,717.99
Rate for Payer: Meridian Medicaid	$986.81
Rate for Payer: Meridian Wellcare - Medicare Advantage	$1,803.89
Rate for Payer: MI Amish Medical Board Commercial	$1,975.69
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$518.50
Rate for Payer: PACE Medicare	$1,632.09
Rate for Payer: PACE SWMI	$1,717.99
Rate for Payer: PHP Commercial	$518.50
Rate for Payer: PHP Medicare Advantage	$1,717.99
Rate for Payer: Priority Health Choice Medicaid	$939.74
Rate for Payer: Priority Health Cigna Priority Health	$427.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$5,467.25
Rate for Payer: Priority Health Medicare	$1,717.99
Rate for Payer: Priority Health Narrow Network	$4,373.80
Rate for Payer: Priority Health SBD	$384.30
Rate for Payer: Railroad Medicare Medicare	$1,717.99
Rate for Payer: UHC All Payor (Choice/PPO)	$206.74
Rate for Payer: UHC Dual Complete DSNP	$1,717.99
Rate for Payer: UHC Exchange	$187.95
Rate for Payer: UHC Medicare Advantage	$1,769.53
Rate for Payer: VA VA	$1,717.99

PR DSTR NROLYTC AGNT PARVERTEB FCT SNGL LMBR/SACRAL

Professional

Both

$603.00

Service Code	HCPCS 64635
Min. Negotiated Rate	$122.48
Max. Negotiated Rate	$825.20
Rate for Payer: Aetna Commercial	$283.74
Rate for Payer: BCBS Complete	$128.60
Rate for Payer: BCBS Trust/PPO	$825.20
Rate for Payer: Cash Price	$482.40
Rate for Payer: Cash Price	$482.40
Rate for Payer: Mclaren Medicaid	$122.48
Rate for Payer: Meridian Medicaid	$128.60
Rate for Payer: Priority Health Choice Medicaid	$122.48
Rate for Payer: Priority Health Cigna Priority Health	$422.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$320.48
Rate for Payer: Priority Health Narrow Network	$320.48
Rate for Payer: Priority Health SBD	$320.48

PR DSTR NROLYTC AGNT PARVERTEB FCT SNGL LMBR/SACRAL

Facility

$603.00

Service Code	CPT 64635
Hospital Charge Code	64635
Min. Negotiated Rate	$379.89
Max. Negotiated Rate	$542.70
Rate for Payer: Aetna Commercial	$512.55
Rate for Payer: Aetna New Business (MI Preferred)	$391.95
Rate for Payer: Cash Price	$482.40
Rate for Payer: Cofinity Commercial	$518.58
Rate for Payer: Cofinity Commercial	$422.10
Rate for Payer: Healthscope Commercial	$542.70
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$512.55
Rate for Payer: PHP Commercial	$512.55
Rate for Payer: Priority Health Cigna Priority Health	$422.10
Rate for Payer: Priority Health SBD	$379.89

PR DSTR NROLYTC AGNT PARVERTEB FCT SNGL LMBR/SACRAL

Professional

Both

$603.00

Service Code	HCPCS 64635
Hospital Charge Code	64635
Min. Negotiated Rate	$122.48
Max. Negotiated Rate	$825.20
Rate for Payer: Aetna Commercial	$283.74
Rate for Payer: BCBS Complete	$128.60
Rate for Payer: BCBS Trust/PPO	$825.20
Rate for Payer: Cash Price	$482.40
Rate for Payer: Cash Price	$482.40
Rate for Payer: Mclaren Medicaid	$122.48
Rate for Payer: Meridian Medicaid	$128.60
Rate for Payer: Priority Health Choice Medicaid	$122.48
Rate for Payer: Priority Health Cigna Priority Health	$422.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$320.48
Rate for Payer: Priority Health Narrow Network	$320.48
Rate for Payer: Priority Health SBD	$320.48

PR DSTR NROLYTC AGNT PARVERTEB FCT SNGL LMBR/SACRAL

Facility

$603.00

Service Code	CPT 64635
Hospital Charge Code	64635
Min. Negotiated Rate	$188.28
Max. Negotiated Rate	$5,467.25
Rate for Payer: Aetna Commercial	$512.55
Rate for Payer: Aetna Medicare	$1,786.71
Rate for Payer: Aetna New Business (MI Preferred)	$391.95
Rate for Payer: Allen County Amish Medical Aid Commercial	$2,147.49
Rate for Payer: Amish Plain Church Group Commercial	$2,147.49
Rate for Payer: BCBS Complete	$986.81
Rate for Payer: BCBS MAPPO	$1,717.99
Rate for Payer: BCBS Trust/PPO	$860.30
Rate for Payer: BCN Medicare Advantage	$1,717.99
Rate for Payer: Cash Price	$482.40
Rate for Payer: Cash Price	$482.40
Rate for Payer: Cofinity Commercial	$422.10
Rate for Payer: Cofinity Commercial	$518.58
Rate for Payer: Health Alliance Plan Medicare Advantage	$1,717.99
Rate for Payer: Healthscope Commercial	$542.70
Rate for Payer: Mclaren Medicaid	$939.74
Rate for Payer: Mclaren Medicare	$1,717.99
Rate for Payer: Meridian Medicaid	$986.81
Rate for Payer: Meridian Wellcare - Medicare Advantage	$1,803.89
Rate for Payer: MI Amish Medical Board Commercial	$1,975.69
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$512.55
Rate for Payer: PACE Medicare	$1,632.09
Rate for Payer: PACE SWMI	$1,717.99
Rate for Payer: PHP Commercial	$512.55
Rate for Payer: PHP Medicare Advantage	$1,717.99
Rate for Payer: Priority Health Choice Medicaid	$939.74
Rate for Payer: Priority Health Cigna Priority Health	$422.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$5,467.25
Rate for Payer: Priority Health Medicare	$1,717.99
Rate for Payer: Priority Health Narrow Network	$4,373.80
Rate for Payer: Priority Health SBD	$379.89
Rate for Payer: Railroad Medicare Medicare	$1,717.99
Rate for Payer: UHC All Payor (Choice/PPO)	$207.11
Rate for Payer: UHC Dual Complete DSNP	$1,717.99
Rate for Payer: UHC Exchange	$188.28
Rate for Payer: UHC Medicare Advantage	$1,769.53
Rate for Payer: VA VA	$1,717.99

PR DTAP-HEPB-IPV VACCINE INTRAMUSCULAR

Professional

Both

$120.00

Service Code	HCPCS 90723
Min. Negotiated Rate	$48.00
Max. Negotiated Rate	$95.50
Rate for Payer: Aetna Commercial	$95.50
Rate for Payer: BCBS Complete	$48.00
Rate for Payer: BCBS Trust/PPO	$89.92
Rate for Payer: Cash Price	$96.00
Rate for Payer: Cash Price	$96.00
Rate for Payer: Priority Health Cigna Priority Health	$84.00

PR DTAP-IPV-HIB-HEPB VACCINE INTRAMUSCULAR

Professional

Both

$160.00

Service Code	HCPCS 90697
Min. Negotiated Rate	$64.00
Max. Negotiated Rate	$175.01
Rate for Payer: Aetna Commercial	$154.01
Rate for Payer: BCBS Complete	$64.00
Rate for Payer: BCBS Trust/PPO	$175.01
Rate for Payer: Cash Price	$128.00
Rate for Payer: Cash Price	$128.00
Rate for Payer: Priority Health Cigna Priority Health	$112.00

PR DTAP-IPV/HIB VACCINE FOR INTRAMUSCULAR USE

Professional

Both

$108.00

Service Code	HCPCS 90698
Min. Negotiated Rate	$43.20
Max. Negotiated Rate	$118.20
Rate for Payer: Aetna Commercial	$118.20
Rate for Payer: BCBS Complete	$43.20
Rate for Payer: BCBS Trust/PPO	$109.23
Rate for Payer: Cash Price	$86.40
Rate for Payer: Cash Price	$86.40
Rate for Payer: Priority Health Cigna Priority Health	$75.60

PR DTAP-IPV VACCINE CHILD 4-6 YRS FOR IM USE

Professional

Both

$67.00

Service Code	HCPCS 90696
Min. Negotiated Rate	$26.80
Max. Negotiated Rate	$62.89
Rate for Payer: Aetna Commercial	$62.89
Rate for Payer: BCBS Complete	$26.80
Rate for Payer: BCBS Trust/PPO	$59.91
Rate for Payer: Cash Price	$53.60
Rate for Payer: Cash Price	$53.60
Rate for Payer: Priority Health Cigna Priority Health	$46.90

PR DTP/HIB VACCINE,IM

Professional

Both

$80.00

Service Code	HCPCS 90720
Min. Negotiated Rate	$32.00
Max. Negotiated Rate	$56.00
Rate for Payer: BCBS Complete	$32.00
Rate for Payer: Cash Price	$64.00
Rate for Payer: Priority Health Cigna Priority Health	$56.00

PR DT VACCINE YOUNGER THAN 7 YRS FOR IM USE

Professional

Both

$44.00

Service Code	HCPCS 90702
Min. Negotiated Rate	$17.60
Max. Negotiated Rate	$79.01
Rate for Payer: Aetna Commercial	$67.16
Rate for Payer: BCBS Complete	$17.60
Rate for Payer: BCBS Trust/PPO	$79.01
Rate for Payer: Cash Price	$35.20
Rate for Payer: Cash Price	$35.20
Rate for Payer: Priority Health Cigna Priority Health	$30.80

Know your out-of-pocket cost for care.

All Charges