Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

PR OSTEOTOMY SPINE POSTERIOR 3 COLUMN EA ADDL SGM

Professional

Both

$2,657.00

Service Code	HCPCS 22208
Min. Negotiated Rate	$375.52
Max. Negotiated Rate	$13,048.08
Rate for Payer: Aetna Commercial	$790.71
Rate for Payer: BCBS Complete	$394.30
Rate for Payer: BCBS Trust/PPO	$13,048.08
Rate for Payer: Cash Price	$2,125.60
Rate for Payer: Cash Price	$2,125.60
Rate for Payer: Mclaren Medicaid	$375.52
Rate for Payer: Meridian Medicaid	$394.30
Rate for Payer: Priority Health Choice Medicaid	$375.52
Rate for Payer: Priority Health Cigna Priority Health	$1,859.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$893.13
Rate for Payer: Priority Health Narrow Network	$893.13
Rate for Payer: Priority Health SBD	$893.13

PR OSTEOTOMY SPINE POSTERIOR 3 COLUMN LUMBAR

Professional

Both

$4,916.86

Service Code	HCPCS 22207
Min. Negotiated Rate	$950.50
Max. Negotiated Rate	$3,668.00
Rate for Payer: Aetna Commercial	$3,215.31
Rate for Payer: BCBS Complete	$1,620.35
Rate for Payer: BCBS Trust/PPO	$950.50
Rate for Payer: Cash Price	$3,933.49
Rate for Payer: Cash Price	$3,933.49
Rate for Payer: Mclaren Medicaid	$1,543.19
Rate for Payer: Meridian Medicaid	$1,620.35
Rate for Payer: Priority Health Choice Medicaid	$1,543.19
Rate for Payer: Priority Health Cigna Priority Health	$3,441.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$3,668.00
Rate for Payer: Priority Health Narrow Network	$3,668.00
Rate for Payer: Priority Health SBD	$3,668.00

PR OSTEOTOMY SPINE POSTERIOR 3 COLUMN THORACIC

Professional

Both

$5,020.60

Service Code	HCPCS 22206
Min. Negotiated Rate	$1,577.48
Max. Negotiated Rate	$17,177.60
Rate for Payer: Aetna Commercial	$3,283.38
Rate for Payer: BCBS Complete	$1,656.35
Rate for Payer: BCBS Trust/PPO	$17,177.60
Rate for Payer: Cash Price	$4,016.48
Rate for Payer: Cash Price	$4,016.48
Rate for Payer: Mclaren Medicaid	$1,577.48
Rate for Payer: Meridian Medicaid	$1,656.35
Rate for Payer: Priority Health Choice Medicaid	$1,577.48
Rate for Payer: Priority Health Cigna Priority Health	$3,514.42
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$3,743.06
Rate for Payer: Priority Health Narrow Network	$3,743.06
Rate for Payer: Priority Health SBD	$3,743.06

PR OSTEOTOMY SPINE PST/PSTLAT APPR 1 VRT SGM CRV

Professional

Both

$3,652.78

Service Code	HCPCS 22210
Min. Negotiated Rate	$1,155.53
Max. Negotiated Rate	$13,048.08
Rate for Payer: Aetna Commercial	$2,400.84
Rate for Payer: BCBS Complete	$1,213.31
Rate for Payer: BCBS Trust/PPO	$13,048.08
Rate for Payer: Cash Price	$2,922.22
Rate for Payer: Cash Price	$2,922.22
Rate for Payer: Mclaren Medicaid	$1,155.53
Rate for Payer: Meridian Medicaid	$1,213.31
Rate for Payer: Priority Health Choice Medicaid	$1,155.53
Rate for Payer: Priority Health Cigna Priority Health	$2,556.95
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,738.62
Rate for Payer: Priority Health Narrow Network	$2,738.62
Rate for Payer: Priority Health SBD	$2,738.62

PR OSTEOTOMY SPINE PST/PSTLAT APPR 1 VRT SGM LMBR

Professional

Both

$3,038.92

Service Code	HCPCS 22214
Min. Negotiated Rate	$978.10
Max. Negotiated Rate	$17,177.60
Rate for Payer: Aetna Commercial	$2,016.15
Rate for Payer: BCBS Complete	$1,027.00
Rate for Payer: BCBS Trust/PPO	$17,177.60
Rate for Payer: Cash Price	$2,431.14
Rate for Payer: Cash Price	$2,431.14
Rate for Payer: Mclaren Medicaid	$978.10
Rate for Payer: Meridian Medicaid	$1,027.00
Rate for Payer: Priority Health Choice Medicaid	$978.10
Rate for Payer: Priority Health Cigna Priority Health	$2,127.24
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,322.44
Rate for Payer: Priority Health Narrow Network	$2,322.44
Rate for Payer: Priority Health SBD	$2,322.44

PR OSTEOTOMY SPINE PST/PSTLAT APPR 1 VRT SGM THRC

Professional

Both

$3,026.04

Service Code	HCPCS 22212
Min. Negotiated Rate	$24.96
Max. Negotiated Rate	$2,321.92
Rate for Payer: Aetna Commercial	$2,011.70
Rate for Payer: BCBS Complete	$1,026.77
Rate for Payer: BCBS Trust/PPO	$24.96
Rate for Payer: Cash Price	$2,420.83
Rate for Payer: Cash Price	$2,420.83
Rate for Payer: Mclaren Medicaid	$977.88
Rate for Payer: Meridian Medicaid	$1,026.77
Rate for Payer: Priority Health Choice Medicaid	$977.88
Rate for Payer: Priority Health Cigna Priority Health	$2,118.23
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,321.92
Rate for Payer: Priority Health Narrow Network	$2,321.92
Rate for Payer: Priority Health SBD	$2,321.92

PR OSTEOTOMY SPINE W/DSC ANT APPR 1 VRT SGM CRV

Professional

Both

$3,225.00

Service Code	HCPCS 22220
Min. Negotiated Rate	$180.34
Max. Negotiated Rate	$2,484.31
Rate for Payer: Aetna Commercial	$2,167.65
Rate for Payer: BCBS Complete	$1,097.45
Rate for Payer: BCBS Trust/PPO	$180.34
Rate for Payer: Cash Price	$2,580.00
Rate for Payer: Cash Price	$2,580.00
Rate for Payer: Mclaren Medicaid	$1,045.19
Rate for Payer: Meridian Medicaid	$1,097.45
Rate for Payer: Priority Health Choice Medicaid	$1,045.19
Rate for Payer: Priority Health Cigna Priority Health	$2,257.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,484.31
Rate for Payer: Priority Health Narrow Network	$2,484.31
Rate for Payer: Priority Health SBD	$2,484.31

PR OSTEOTOMY SPINE W/DSC ANT APPR 1 VRT SGM EA ADDL

Professional

Both

$656.00

Service Code	HCPCS 22226
Min. Negotiated Rate	$227.91
Max. Negotiated Rate	$544.36
Rate for Payer: Aetna Commercial	$486.64
Rate for Payer: BCBS Complete	$239.31
Rate for Payer: BCBS Trust/PPO	$233.52
Rate for Payer: Cash Price	$524.80
Rate for Payer: Cash Price	$524.80
Rate for Payer: Mclaren Medicaid	$227.91
Rate for Payer: Meridian Medicaid	$239.31
Rate for Payer: Priority Health Choice Medicaid	$227.91
Rate for Payer: Priority Health Cigna Priority Health	$459.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$544.36
Rate for Payer: Priority Health Narrow Network	$544.36
Rate for Payer: Priority Health SBD	$544.36

PR OSTEOTOMY SPINE W/DSC ANT APPR 1 VRT SGM LUMBAR

Professional

Both

$3,215.24

Service Code	HCPCS 22224
Min. Negotiated Rate	$180.34
Max. Negotiated Rate	$2,423.55
Rate for Payer: Aetna Commercial	$2,126.35
Rate for Payer: BCBS Complete	$1,069.94
Rate for Payer: BCBS Trust/PPO	$180.34
Rate for Payer: Cash Price	$2,572.19
Rate for Payer: Cash Price	$2,572.19
Rate for Payer: Mclaren Medicaid	$1,018.99
Rate for Payer: Meridian Medicaid	$1,069.94
Rate for Payer: Priority Health Choice Medicaid	$1,018.99
Rate for Payer: Priority Health Cigna Priority Health	$2,250.67
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,423.55
Rate for Payer: Priority Health Narrow Network	$2,423.55
Rate for Payer: Priority Health SBD	$2,423.55

PR OSTEOTOMY TARSAL BONES OTH/THN CALCANEUS/TALUS

Professional

Both

$1,486.00

Service Code	HCPCS 28304
Min. Negotiated Rate	$395.75
Max. Negotiated Rate	$1,184.98
Rate for Payer: Aetna Commercial	$807.84
Rate for Payer: BCBS Complete	$415.54
Rate for Payer: BCBS Trust/PPO	$1,184.98
Rate for Payer: Cash Price	$1,188.80
Rate for Payer: Cash Price	$1,188.80
Rate for Payer: Mclaren Medicaid	$395.75
Rate for Payer: Meridian Medicaid	$415.54
Rate for Payer: Priority Health Choice Medicaid	$395.75
Rate for Payer: Priority Health Cigna Priority Health	$1,040.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$939.09
Rate for Payer: Priority Health Narrow Network	$939.09
Rate for Payer: Priority Health SBD	$939.09

PR OSTEOTOMY TIBIA

Professional

Both

$2,976.00

Service Code	HCPCS 27705
Min. Negotiated Rate	$483.51
Max. Negotiated Rate	$2,650.81
Rate for Payer: Aetna Commercial	$1,009.73
Rate for Payer: BCBS Complete	$507.69
Rate for Payer: BCBS Trust/PPO	$2,650.81
Rate for Payer: Cash Price	$2,380.80
Rate for Payer: Cash Price	$2,380.80
Rate for Payer: Mclaren Medicaid	$483.51
Rate for Payer: Meridian Medicaid	$507.69
Rate for Payer: Priority Health Choice Medicaid	$483.51
Rate for Payer: Priority Health Cigna Priority Health	$2,083.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,157.13
Rate for Payer: Priority Health Narrow Network	$1,157.13
Rate for Payer: Priority Health SBD	$1,157.13

PR OSTEOTOMY TIBIA & FIBULA

Professional

Both

$3,401.00

Service Code	HCPCS 27709
Min. Negotiated Rate	$490.37
Max. Negotiated Rate	$2,380.70
Rate for Payer: Aetna Commercial	$1,543.67
Rate for Payer: BCBS Complete	$772.26
Rate for Payer: BCBS Trust/PPO	$490.37
Rate for Payer: Cash Price	$2,720.80
Rate for Payer: Cash Price	$2,720.80
Rate for Payer: Mclaren Medicaid	$735.49
Rate for Payer: Meridian Medicaid	$772.26
Rate for Payer: Priority Health Choice Medicaid	$735.49
Rate for Payer: Priority Health Cigna Priority Health	$2,380.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,733.66
Rate for Payer: Priority Health Narrow Network	$1,733.66
Rate for Payer: Priority Health SBD	$1,733.66

PR OSTEOTOMY&TRANSFER GREATER TROCHANTER SPX

Professional

Both

$3,102.00

Service Code	HCPCS 27140
Min. Negotiated Rate	$578.51
Max. Negotiated Rate	$2,171.40
Rate for Payer: Aetna Commercial	$1,192.72
Rate for Payer: BCBS Complete	$607.44
Rate for Payer: BCBS Trust/PPO	$1,363.54
Rate for Payer: Cash Price	$2,481.60
Rate for Payer: Cash Price	$2,481.60
Rate for Payer: Mclaren Medicaid	$578.51
Rate for Payer: Meridian Medicaid	$607.44
Rate for Payer: Priority Health Choice Medicaid	$578.51
Rate for Payer: Priority Health Cigna Priority Health	$2,171.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,375.18
Rate for Payer: Priority Health Narrow Network	$1,375.18
Rate for Payer: Priority Health SBD	$1,375.18

PR OSTEOTOMY ULNA

Professional

Both

$2,184.00

Service Code	HCPCS 25360
Min. Negotiated Rate	$426.64
Max. Negotiated Rate	$1,528.80
Rate for Payer: Aetna Commercial	$871.38
Rate for Payer: BCBS Complete	$447.97
Rate for Payer: BCBS Trust/PPO	$677.28
Rate for Payer: Cash Price	$1,747.20
Rate for Payer: Cash Price	$1,747.20
Rate for Payer: Mclaren Medicaid	$426.64
Rate for Payer: Meridian Medicaid	$447.97
Rate for Payer: Priority Health Choice Medicaid	$426.64
Rate for Payer: Priority Health Cigna Priority Health	$1,528.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,012.61
Rate for Payer: Priority Health Narrow Network	$1,012.61
Rate for Payer: Priority Health SBD	$1,012.61

PR OSTEOT PROX TIBIA FIB EXC/OSTEOT AFTER EPIPHYSL

Professional

Both

$2,670.00

Service Code	HCPCS 27457
Min. Negotiated Rate	$607.69
Max. Negotiated Rate	$1,869.00
Rate for Payer: Aetna Commercial	$1,285.67
Rate for Payer: BCBS Complete	$638.07
Rate for Payer: BCBS Trust/PPO	$1,269.50
Rate for Payer: Cash Price	$2,136.00
Rate for Payer: Cash Price	$2,136.00
Rate for Payer: Mclaren Medicaid	$607.69
Rate for Payer: Meridian Medicaid	$638.07
Rate for Payer: Priority Health Choice Medicaid	$607.69
Rate for Payer: Priority Health Cigna Priority Health	$1,869.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,472.21
Rate for Payer: Priority Health Narrow Network	$1,472.21
Rate for Payer: Priority Health SBD	$1,472.21

PR OSTEOT PROX TIBIA FIB EXC/OSTEOT BEFORE EPIPHYSL

Professional

Both

$1,993.00

Service Code	HCPCS 27455
Min. Negotiated Rate	$619.40
Max. Negotiated Rate	$1,475.78
Rate for Payer: Aetna Commercial	$1,279.84
Rate for Payer: BCBS Complete	$650.37
Rate for Payer: BCBS Trust/PPO	$1,212.98
Rate for Payer: Cash Price	$1,594.40
Rate for Payer: Cash Price	$1,594.40
Rate for Payer: Mclaren Medicaid	$619.40
Rate for Payer: Meridian Medicaid	$650.37
Rate for Payer: Priority Health Choice Medicaid	$619.40
Rate for Payer: Priority Health Cigna Priority Health	$1,395.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,475.78
Rate for Payer: Priority Health Narrow Network	$1,475.78
Rate for Payer: Priority Health SBD	$1,475.78

PR OSTEOT SHRT CORRJ OTH PHALANGES ANY TOE

Professional

Both

$795.00

Service Code	HCPCS 28312
Min. Negotiated Rate	$223.22
Max. Negotiated Rate	$1,771.92
Rate for Payer: Aetna Commercial	$424.19
Rate for Payer: BCBS Complete	$234.38
Rate for Payer: BCBS Trust/PPO	$1,771.92
Rate for Payer: Cash Price	$636.00
Rate for Payer: Cash Price	$636.00
Rate for Payer: Mclaren Medicaid	$223.22
Rate for Payer: Meridian Medicaid	$234.38
Rate for Payer: Priority Health Choice Medicaid	$223.22
Rate for Payer: Priority Health Cigna Priority Health	$556.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$516.27
Rate for Payer: Priority Health Narrow Network	$516.27
Rate for Payer: Priority Health SBD	$516.27

PR OSTEOT SHRT CORRJ PROX PHALANX 1ST TOE

Professional

Both

$937.00

Service Code	HCPCS 28310
Min. Negotiated Rate	$234.94
Max. Negotiated Rate	$1,691.62
Rate for Payer: Aetna Commercial	$478.50
Rate for Payer: BCBS Complete	$246.69
Rate for Payer: BCBS Trust/PPO	$1,691.62
Rate for Payer: Cash Price	$749.60
Rate for Payer: Cash Price	$749.60
Rate for Payer: Mclaren Medicaid	$234.94
Rate for Payer: Meridian Medicaid	$246.69
Rate for Payer: Priority Health Choice Medicaid	$234.94
Rate for Payer: Priority Health Cigna Priority Health	$655.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$550.47
Rate for Payer: Priority Health Narrow Network	$550.47
Rate for Payer: Priority Health SBD	$550.47

PR OSTEOT SPI PST/PSTLAT APPR 1 VRT SGM EA VRT SGM

Professional

Both

$2,585.00

Service Code	HCPCS 22216
Min. Negotiated Rate	$106.88
Max. Negotiated Rate	$1,809.50
Rate for Payer: Aetna Commercial	$489.31
Rate for Payer: BCBS Complete	$241.76
Rate for Payer: BCBS Trust/PPO	$106.88
Rate for Payer: Cash Price	$2,068.00
Rate for Payer: Cash Price	$2,068.00
Rate for Payer: Mclaren Medicaid	$230.25
Rate for Payer: Meridian Medicaid	$241.76
Rate for Payer: Priority Health Choice Medicaid	$230.25
Rate for Payer: Priority Health Cigna Priority Health	$1,809.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$550.47
Rate for Payer: Priority Health Narrow Network	$550.47
Rate for Payer: Priority Health SBD	$550.47

PR OSTEOT TARSAL OTH/THN CALCANEUS/TALUS W/AGRFT

Professional

Both

$1,688.00

Service Code	HCPCS 28305
Min. Negotiated Rate	$434.52
Max. Negotiated Rate	$1,202.94
Rate for Payer: Aetna Commercial	$901.63
Rate for Payer: BCBS Complete	$456.25
Rate for Payer: BCBS Trust/PPO	$1,202.94
Rate for Payer: Cash Price	$1,350.40
Rate for Payer: Cash Price	$1,350.40
Rate for Payer: Mclaren Medicaid	$434.52
Rate for Payer: Meridian Medicaid	$456.25
Rate for Payer: Priority Health Choice Medicaid	$434.52
Rate for Payer: Priority Health Cigna Priority Health	$1,181.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,023.34
Rate for Payer: Priority Health Narrow Network	$1,023.34
Rate for Payer: Priority Health SBD	$1,023.34

PR OSTEOT W/WO LNGTH SHRT/ANGULAR CORRJ METAR MLT

Professional

Both

$3,884.00

Service Code	HCPCS 28309
Min. Negotiated Rate	$582.34
Max. Negotiated Rate	$2,718.80
Rate for Payer: Aetna Commercial	$1,184.22
Rate for Payer: BCBS Complete	$611.46
Rate for Payer: BCBS Trust/PPO	$1,728.07
Rate for Payer: Cash Price	$3,107.20
Rate for Payer: Cash Price	$3,107.20
Rate for Payer: Mclaren Medicaid	$582.34
Rate for Payer: Meridian Medicaid	$611.46
Rate for Payer: Priority Health Choice Medicaid	$582.34
Rate for Payer: Priority Health Cigna Priority Health	$2,718.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,374.15
Rate for Payer: Priority Health Narrow Network	$1,374.15
Rate for Payer: Priority Health SBD	$1,374.15

PR OSTEOT W/WO LNGTH SHRT/CORRJ 1ST METAR

Professional

Both

$1,389.00

Service Code	HCPCS 28306
Min. Negotiated Rate	$263.27
Max. Negotiated Rate	$1,500.90
Rate for Payer: Aetna Commercial	$529.18
Rate for Payer: BCBS Complete	$276.43
Rate for Payer: BCBS Trust/PPO	$1,500.90
Rate for Payer: Cash Price	$1,111.20
Rate for Payer: Cash Price	$1,111.20
Rate for Payer: Mclaren Medicaid	$263.27
Rate for Payer: Meridian Medicaid	$276.43
Rate for Payer: Priority Health Choice Medicaid	$263.27
Rate for Payer: Priority Health Cigna Priority Health	$972.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$618.90
Rate for Payer: Priority Health Narrow Network	$618.90
Rate for Payer: Priority Health SBD	$618.90

PR OSTEOT W/WO LNGTH SHRT/CORRJ METAR XCP 1ST EA

Professional

Both

$1,066.00

Service Code	HCPCS 28308
Min. Negotiated Rate	$250.91
Max. Negotiated Rate	$1,566.94
Rate for Payer: Aetna Commercial	$506.51
Rate for Payer: BCBS Complete	$263.46
Rate for Payer: BCBS Trust/PPO	$1,566.94
Rate for Payer: Cash Price	$852.80
Rate for Payer: Cash Price	$852.80
Rate for Payer: Mclaren Medicaid	$250.91
Rate for Payer: Meridian Medicaid	$263.46
Rate for Payer: Priority Health Choice Medicaid	$250.91
Rate for Payer: Priority Health Cigna Priority Health	$746.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$589.29
Rate for Payer: Priority Health Narrow Network	$589.29
Rate for Payer: Priority Health SBD	$589.29

PR OSTPL RCNSTJ DORSAL SPI ELMNTS FLWG ISPI PX

Professional

Both

$1,245.00

Service Code	HCPCS 63295
Min. Negotiated Rate	$210.44
Max. Negotiated Rate	$871.50
Rate for Payer: Aetna Commercial	$425.26
Rate for Payer: BCBS Complete	$220.96
Rate for Payer: BCBS Trust/PPO	$256.75
Rate for Payer: Cash Price	$996.00
Rate for Payer: Cash Price	$996.00
Rate for Payer: Mclaren Medicaid	$210.44
Rate for Payer: Meridian Medicaid	$220.96
Rate for Payer: Priority Health Choice Medicaid	$210.44
Rate for Payer: Priority Health Cigna Priority Health	$871.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$559.99
Rate for Payer: Priority Health Narrow Network	$559.99
Rate for Payer: Priority Health SBD	$559.99

PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION

Facility

$45.08

Service Code	HCPCS J2720
Hospital Charge Code	6677
Hospital Revenue Code	636
Min. Negotiated Rate	$28.40
Max. Negotiated Rate	$40.57
Rate for Payer: Aetna Commercial	$38.32
Rate for Payer: Aetna Commercial	$115.09
Rate for Payer: Aetna New Business (MI Preferred)	$29.30
Rate for Payer: Aetna New Business (MI Preferred)	$88.01
Rate for Payer: Cash Price	$36.06
Rate for Payer: Cash Price	$108.32
Rate for Payer: Cofinity Commercial	$38.77
Rate for Payer: Cofinity Commercial	$116.44
Rate for Payer: Cofinity Commercial	$94.78
Rate for Payer: Cofinity Commercial	$31.56
Rate for Payer: Healthscope Commercial	$121.86
Rate for Payer: Healthscope Commercial	$40.57
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$38.32
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$115.09
Rate for Payer: PHP Commercial	$115.09
Rate for Payer: PHP Commercial	$38.32
Rate for Payer: Priority Health Cigna Priority Health	$94.78
Rate for Payer: Priority Health Cigna Priority Health	$31.56
Rate for Payer: Priority Health SBD	$85.30
Rate for Payer: Priority Health SBD	$28.40

Know your out-of-pocket cost for care.

All Charges