Bronson Lakeview Hospital

All Charges

Charge

Type

Setting

Price

PR FRAC THGH/ABD/BACK

Professional

Both

$473.00

Hospital Revenue Code	990
Min. Negotiated Rate	$189.20
Max. Negotiated Rate	$354.75
Rate for Payer: Aetna Medicare	$236.50
Rate for Payer: BCBS Complete	$189.20
Rate for Payer: Cash Price	$378.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$354.75

PR FRACTURE NASAL INFERIOR TURBINATE THERAPEUTIC

Professional

Both

$548.00

Service Code	HCPCS 30930
Min. Negotiated Rate	$69.44
Max. Negotiated Rate	$411.00
Rate for Payer: Aetna Commercial	$147.55
Rate for Payer: Aetna Medicare	$274.00
Rate for Payer: BCBS Complete	$72.91
Rate for Payer: BCN Commercial	$178.77
Rate for Payer: Cash Price	$438.40
Rate for Payer: Cash Price	$438.40
Rate for Payer: Mclaren Medicaid	$69.44
Rate for Payer: Meridian Medicaid	$72.91
Rate for Payer: Opus (Opus Packaging Group) HMA	$411.00
Rate for Payer: Priority Health Choice Medicaid	$69.44
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$168.35
Rate for Payer: Priority Health Narrow/Tiered Network	$168.35
Rate for Payer: UHC Medicaid	$69.44
Rate for Payer: UHCCP Medicaid	$69.44

PR FRAC UP/LOW FACE

Professional

Both

$263.00

Hospital Revenue Code	990
Min. Negotiated Rate	$105.20
Max. Negotiated Rate	$197.25
Rate for Payer: Aetna Medicare	$131.50
Rate for Payer: BCBS Complete	$105.20
Rate for Payer: Cash Price	$210.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$197.25

PR FRENOPLASTY SURG REVJ FRENUM EG W/Z-PLASTY

Professional

Both

$586.00

Service Code	HCPCS 41520
Min. Negotiated Rate	$146.97
Max. Negotiated Rate	$463.57
Rate for Payer: Aetna Commercial	$326.38
Rate for Payer: Aetna Medicare	$293.00
Rate for Payer: BCBS Complete	$154.32
Rate for Payer: BCN Commercial	$380.46
Rate for Payer: Cash Price	$468.80
Rate for Payer: Cash Price	$468.80
Rate for Payer: Mclaren Medicaid	$146.97
Rate for Payer: Meridian Medicaid	$154.32
Rate for Payer: Opus (Opus Packaging Group) HMA	$439.50
Rate for Payer: Priority Health Choice Medicaid	$146.97
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$463.57
Rate for Payer: Priority Health Narrow/Tiered Network	$463.57
Rate for Payer: UHC Medicaid	$146.97
Rate for Payer: UHCCP Medicaid	$146.97

PR FRENULOTOMY PENIS

Professional

Both

$850.00

Service Code	HCPCS 54164
Min. Negotiated Rate	$118.22
Max. Negotiated Rate	$637.50
Rate for Payer: Aetna Commercial	$244.64
Rate for Payer: Aetna Medicare	$425.00
Rate for Payer: BCBS Complete	$124.13
Rate for Payer: BCN Commercial	$295.30
Rate for Payer: Cash Price	$680.00
Rate for Payer: Cash Price	$680.00
Rate for Payer: Mclaren Medicaid	$118.22
Rate for Payer: Meridian Medicaid	$124.13
Rate for Payer: Opus (Opus Packaging Group) HMA	$637.50
Rate for Payer: Priority Health Choice Medicaid	$118.22
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$321.67
Rate for Payer: Priority Health Narrow/Tiered Network	$321.67
Rate for Payer: UHC Medicaid	$118.22
Rate for Payer: UHCCP Medicaid	$118.22

PR FRMJ DIRECT/TUBED PEDICLE W/WO TRANSFER TRUNK

Professional

Both

$1,548.00

Service Code	HCPCS 15570
Min. Negotiated Rate	$428.98
Max. Negotiated Rate	$1,161.00
Rate for Payer: Aetna Commercial	$788.69
Rate for Payer: Aetna Medicare	$774.00
Rate for Payer: BCBS Complete	$450.43
Rate for Payer: BCN Commercial	$1,098.05
Rate for Payer: Cash Price	$1,238.40
Rate for Payer: Cash Price	$1,238.40
Rate for Payer: Mclaren Medicaid	$428.98
Rate for Payer: Meridian Medicaid	$450.43
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,161.00
Rate for Payer: Priority Health Choice Medicaid	$428.98
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$1,005.00
Rate for Payer: Priority Health Narrow/Tiered Network	$1,005.00
Rate for Payer: UHC Medicaid	$428.98
Rate for Payer: UHCCP Medicaid	$428.98

PR FRMJ DIRECT/TUBED PEDICLE W/WOTR E/N/E/L/NTRORAL

Professional

Both

$1,672.00

Service Code	HCPCS 15576
Min. Negotiated Rate	$359.33
Max. Negotiated Rate	$1,254.00
Rate for Payer: Aetna Commercial	$703.16
Rate for Payer: Aetna Medicare	$836.00
Rate for Payer: BCBS Complete	$377.30
Rate for Payer: BCN Commercial	$977.53
Rate for Payer: Cash Price	$1,337.60
Rate for Payer: Cash Price	$1,337.60
Rate for Payer: Mclaren Medicaid	$359.33
Rate for Payer: Meridian Medicaid	$377.30
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,254.00
Rate for Payer: Priority Health Choice Medicaid	$359.33
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$894.70
Rate for Payer: Priority Health Narrow/Tiered Network	$894.70
Rate for Payer: UHC Medicaid	$359.33
Rate for Payer: UHCCP Medicaid	$359.33

PR FRMJ DIRECT/TUBE PEDICLE W/WO TR SCALP ARMS/LEGS

Professional

Both

$1,613.00

Service Code	HCPCS 15572
Min. Negotiated Rate	$427.28
Max. Negotiated Rate	$1,209.75
Rate for Payer: Aetna Commercial	$789.01
Rate for Payer: Aetna Medicare	$806.50
Rate for Payer: BCBS Complete	$448.64
Rate for Payer: BCN Commercial	$1,112.49
Rate for Payer: Cash Price	$1,290.40
Rate for Payer: Cash Price	$1,290.40
Rate for Payer: Mclaren Medicaid	$427.28
Rate for Payer: Meridian Medicaid	$448.64
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,209.75
Rate for Payer: Priority Health Choice Medicaid	$427.28
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$1,018.21
Rate for Payer: Priority Health Narrow/Tiered Network	$1,018.21
Rate for Payer: UHC Medicaid	$427.28
Rate for Payer: UHCCP Medicaid	$427.28

PR FRMJ DIR/TUBE PEDCL W/WOTR FH/CH/CH/M/N/AX/G/H/F

Professional

Both

$1,976.00

Service Code	HCPCS 15574
Min. Negotiated Rate	$407.90
Max. Negotiated Rate	$1,482.00
Rate for Payer: Aetna Commercial	$791.76
Rate for Payer: Aetna Medicare	$988.00
Rate for Payer: BCBS Complete	$428.30
Rate for Payer: BCN Commercial	$1,089.09
Rate for Payer: Cash Price	$1,580.80
Rate for Payer: Cash Price	$1,580.80
Rate for Payer: Mclaren Medicaid	$407.90
Rate for Payer: Meridian Medicaid	$428.30
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,482.00
Rate for Payer: Priority Health Choice Medicaid	$407.90
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$996.80
Rate for Payer: Priority Health Narrow/Tiered Network	$996.80
Rate for Payer: UHC Medicaid	$407.90
Rate for Payer: UHCCP Medicaid	$407.90

PR FTH/GFT FR DIR CLSR F/C/C/M/N/AX/G/H/F 20SQCM/<

Professional

Both

$1,441.00

Service Code	HCPCS 15240
Min. Negotiated Rate	$445.17
Max. Negotiated Rate	$1,199.63
Rate for Payer: Aetna Commercial	$845.41
Rate for Payer: Aetna Medicare	$720.50
Rate for Payer: BCBS Complete	$467.43
Rate for Payer: BCN Commercial	$1,199.63
Rate for Payer: Cash Price	$1,152.80
Rate for Payer: Cash Price	$1,152.80
Rate for Payer: Mclaren Medicaid	$445.17
Rate for Payer: Meridian Medicaid	$467.43
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,080.75
Rate for Payer: Priority Health Choice Medicaid	$445.17
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$1,097.98
Rate for Payer: Priority Health Narrow/Tiered Network	$1,097.98
Rate for Payer: UHC Medicaid	$445.17
Rate for Payer: UHCCP Medicaid	$445.17

PR FTH/GFT FR DIR CLSR F/C/C/M/N/AX/G/H/F 20SQCM/<

Facility

$1,441.00

Service Code	CPT 15240
Hospital Charge Code	15240
Hospital Revenue Code	960
Min. Negotiated Rate	$1,002.94
Max. Negotiated Rate	$1,296.90
Rate for Payer: Aetna Commercial	$1,224.85
Rate for Payer: BCBS Trust/PPO	$1,190.12
Rate for Payer: BCN Commercial	$1,190.12
Rate for Payer: Cash Price	$1,152.80
Rate for Payer: Cofinity Commercial	$1,239.26
Rate for Payer: Encore Health Key Benefits Commercial	$1,152.80
Rate for Payer: Healthscope Commercial	$1,296.90
Rate for Payer: Lakeland Regional Health Systems Commercial	$1,080.75
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,224.85
Rate for Payer: Nomi Health Commercial	$1,181.62
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,080.75
Rate for Payer: PHP Commercial	$1,224.85
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$1,253.67
Rate for Payer: Priority Health Narrow/Tiered Network	$1,002.94
Rate for Payer: UHC Core	$1,203.23
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$1,080.75

PR FTH/GFT FR DIR CLSR F/C/C/M/N/AX/G/H/F 20SQCM/<

Professional

Both

$1,441.00

Service Code	HCPCS 15240
Hospital Charge Code	15240
Min. Negotiated Rate	$445.17
Max. Negotiated Rate	$1,199.63
Rate for Payer: Aetna Commercial	$845.41
Rate for Payer: Aetna Medicare	$720.50
Rate for Payer: BCBS Complete	$467.43
Rate for Payer: BCN Commercial	$1,199.63
Rate for Payer: Cash Price	$1,152.80
Rate for Payer: Cash Price	$1,152.80
Rate for Payer: Mclaren Medicaid	$445.17
Rate for Payer: Meridian Medicaid	$467.43
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,080.75
Rate for Payer: Priority Health Choice Medicaid	$445.17
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$1,097.98
Rate for Payer: Priority Health Narrow/Tiered Network	$1,097.98
Rate for Payer: UHC Medicaid	$445.17
Rate for Payer: UHCCP Medicaid	$445.17

PR FTH/GFT FR DIR CLSR F/C/C/M/N/AX/G/H/F 20SQCM/<

Facility

$1,441.00

Service Code	CPT 15240
Hospital Charge Code	15240
Hospital Revenue Code	960
Min. Negotiated Rate	$254.05
Max. Negotiated Rate	$1,296.90
Rate for Payer: Aetna Commercial	$1,224.85
Rate for Payer: Aetna Medicare	$374.66
Rate for Payer: Allen County Amish Medical Aid Commercial	$450.31
Rate for Payer: Amish Plain Church Group Commercial	$450.31
Rate for Payer: BCBS Complete	$266.73
Rate for Payer: BCBS MAPPO	$360.25
Rate for Payer: BCBS Trust/PPO	$1,184.65
Rate for Payer: BCN Commercial	$1,184.65
Rate for Payer: BCN Medicare Advantage	$360.25
Rate for Payer: Cash Price	$1,152.80
Rate for Payer: Cofinity Commercial	$1,239.26
Rate for Payer: Encore Health Key Benefits Commercial	$1,152.80
Rate for Payer: Health Alliance Plan Medicare Advantage	$360.25
Rate for Payer: Healthscope Commercial	$1,296.90
Rate for Payer: Lakeland Regional Health Systems Commercial	$1,080.75
Rate for Payer: Mclaren Medicaid	$254.05
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$378.26
Rate for Payer: Meridian Medicaid	$266.73
Rate for Payer: MI Amish Medical Board Commercial	$414.29
Rate for Payer: Molina Medicare/Medicaid	$396.27
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,224.85
Rate for Payer: Nomi Health Commercial	$1,181.62
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,080.75
Rate for Payer: PACE Senior Care Partners	$342.24
Rate for Payer: PACE SWMI	$360.25
Rate for Payer: PHP Commercial	$1,224.85
Rate for Payer: PHP Medicare Advantage	$360.25
Rate for Payer: Priority Health Choice Medicaid	$254.05
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$1,253.67
Rate for Payer: Priority Health Medicare	$363.85
Rate for Payer: Priority Health Narrow/Tiered Network	$1,002.94
Rate for Payer: Railroad Medicare Medicare	$360.25
Rate for Payer: UHC Core	$1,203.23
Rate for Payer: UHC Exchange	$360.25
Rate for Payer: UHC Medicaid	$254.05
Rate for Payer: UHC Medicare Advantage	$360.25
Rate for Payer: UHCCP Medicaid	$254.05
Rate for Payer: VA VA	$360.25
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$1,080.75

PR FTH/GFT FREE W/DIR CLSR N/E/E/L EA ADDL 20 SQ CM

Professional

Both

$439.00

Service Code	HCPCS 15261
Min. Negotiated Rate	$71.78
Max. Negotiated Rate	$329.25
Rate for Payer: Aetna Commercial	$147.92
Rate for Payer: Aetna Medicare	$219.50
Rate for Payer: BCBS Complete	$75.37
Rate for Payer: BCN Commercial	$200.69
Rate for Payer: Cash Price	$351.20
Rate for Payer: Cash Price	$351.20
Rate for Payer: Mclaren Medicaid	$71.78
Rate for Payer: Meridian Medicaid	$75.37
Rate for Payer: Opus (Opus Packaging Group) HMA	$329.25
Rate for Payer: Priority Health Choice Medicaid	$71.78
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$183.69
Rate for Payer: Priority Health Narrow/Tiered Network	$183.69
Rate for Payer: UHC Medicaid	$71.78
Rate for Payer: UHCCP Medicaid	$71.78

PR FTH/GFT FREE W/DIRECT CLOSURE N/E/E/L 20 SQ CM/<

Professional

Both

$1,751.00

Service Code	HCPCS 15260
Min. Negotiated Rate	$463.91
Max. Negotiated Rate	$1,313.25
Rate for Payer: Aetna Commercial	$898.38
Rate for Payer: Aetna Medicare	$875.50
Rate for Payer: BCBS Complete	$487.11
Rate for Payer: BCN Commercial	$1,273.83
Rate for Payer: Cash Price	$1,400.80
Rate for Payer: Cash Price	$1,400.80
Rate for Payer: Mclaren Medicaid	$463.91
Rate for Payer: Meridian Medicaid	$487.11
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,313.25
Rate for Payer: Priority Health Choice Medicaid	$463.91
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$1,165.88
Rate for Payer: Priority Health Narrow/Tiered Network	$1,165.88
Rate for Payer: UHC Medicaid	$463.91
Rate for Payer: UHCCP Medicaid	$463.91

PR FTH/GFT FREE W/DIRECT CLOSURE S/A/L 20 SQ CM/<

Professional

Both

$1,740.00

Service Code	HCPCS 15220
Min. Negotiated Rate	$342.93
Max. Negotiated Rate	$1,305.00
Rate for Payer: Aetna Commercial	$650.11
Rate for Payer: Aetna Medicare	$870.00
Rate for Payer: BCBS Complete	$360.08
Rate for Payer: BCN Commercial	$918.78
Rate for Payer: Cash Price	$1,392.00
Rate for Payer: Cash Price	$1,392.00
Rate for Payer: Mclaren Medicaid	$342.93
Rate for Payer: Meridian Medicaid	$360.08
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,305.00
Rate for Payer: Priority Health Choice Medicaid	$342.93
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$840.91
Rate for Payer: Priority Health Narrow/Tiered Network	$840.91
Rate for Payer: UHC Medicaid	$342.93
Rate for Payer: UHCCP Medicaid	$342.93

PR FTH/GFT FREE W/DIRECT CLOSURE TRUNK 20 SQ CM/<

Professional

Both

$1,411.00

Service Code	HCPCS 15200
Min. Negotiated Rate	$385.96
Max. Negotiated Rate	$1,058.25
Rate for Payer: Aetna Commercial	$720.22
Rate for Payer: Aetna Medicare	$705.50
Rate for Payer: BCBS Complete	$405.26
Rate for Payer: BCN Commercial	$1,014.89
Rate for Payer: Cash Price	$1,128.80
Rate for Payer: Cash Price	$1,128.80
Rate for Payer: Mclaren Medicaid	$385.96
Rate for Payer: Meridian Medicaid	$405.26
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,058.25
Rate for Payer: Priority Health Choice Medicaid	$385.96
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$928.88
Rate for Payer: Priority Health Narrow/Tiered Network	$928.88
Rate for Payer: UHC Medicaid	$385.96
Rate for Payer: UHCCP Medicaid	$385.96

PR FTH/GFT FR W/DIR CLSR F/C/C/M/N/AX/G/H/F EA ADDL

Professional

Both

$366.00

Service Code	HCPCS 15241
Min. Negotiated Rate	$57.08
Max. Negotiated Rate	$274.50
Rate for Payer: Aetna Commercial	$115.10
Rate for Payer: Aetna Medicare	$183.00
Rate for Payer: BCBS Complete	$59.93
Rate for Payer: BCN Commercial	$158.86
Rate for Payer: Cash Price	$292.80
Rate for Payer: Cash Price	$292.80
Rate for Payer: Mclaren Medicaid	$57.08
Rate for Payer: Meridian Medicaid	$59.93
Rate for Payer: Opus (Opus Packaging Group) HMA	$274.50
Rate for Payer: Priority Health Choice Medicaid	$57.08
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$145.40
Rate for Payer: Priority Health Narrow/Tiered Network	$145.40
Rate for Payer: UHC Medicaid	$57.08
Rate for Payer: UHCCP Medicaid	$57.08

PR FTH/GFT FR W/DIR CLSR S/A/L EA ADDL 20 SQ CM

Professional

Both

$293.00

Service Code	HCPCS 15221
Min. Negotiated Rate	$36.85
Max. Negotiated Rate	$219.75
Rate for Payer: Aetna Commercial	$75.94
Rate for Payer: Aetna Medicare	$146.50
Rate for Payer: BCBS Complete	$38.69
Rate for Payer: BCN Commercial	$102.59
Rate for Payer: Cash Price	$234.40
Rate for Payer: Cash Price	$234.40
Rate for Payer: Mclaren Medicaid	$36.85
Rate for Payer: Meridian Medicaid	$38.69
Rate for Payer: Opus (Opus Packaging Group) HMA	$219.75
Rate for Payer: Priority Health Choice Medicaid	$36.85
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$93.89
Rate for Payer: Priority Health Narrow/Tiered Network	$93.89
Rate for Payer: UHC Medicaid	$36.85
Rate for Payer: UHCCP Medicaid	$36.85

PR FT INSERT UCB BERKELEY SHELL

Professional

Both

$315.00

Service Code	HCPCS L3000
Min. Negotiated Rate	$126.00
Max. Negotiated Rate	$369.62
Rate for Payer: Aetna Commercial	$189.20
Rate for Payer: Aetna Medicare	$157.50
Rate for Payer: BCBS Complete	$126.00
Rate for Payer: BCN Commercial	$369.62
Rate for Payer: Cash Price	$252.00
Rate for Payer: Cash Price	$252.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$236.25

PR FUNCJAL CORT&SUBCORT MAPG PHYS/QHP ATTND INIT HR

Professional

Both

$529.00

Service Code	HCPCS 95961
Min. Negotiated Rate	$264.50
Max. Negotiated Rate	$489.52
Rate for Payer: Aetna Commercial	$340.39
Rate for Payer: Aetna Medicare	$264.50
Rate for Payer: BCN Commercial	$489.52
Rate for Payer: Cash Price	$423.20
Rate for Payer: Cash Price	$423.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$396.75
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$451.44
Rate for Payer: Priority Health Narrow/Tiered Network	$451.44

PR FUNDUS PHOTOGRAPHY W/INTERPRETATION & REPORT

Professional

Both

$128.00

Service Code	HCPCS 92250
Min. Negotiated Rate	$41.28
Max. Negotiated Rate	$96.00
Rate for Payer: Aetna Commercial	$41.28
Rate for Payer: Aetna Medicare	$64.00
Rate for Payer: BCN Commercial	$54.78
Rate for Payer: Cash Price	$102.40
Rate for Payer: Cash Price	$102.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$96.00
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$46.87
Rate for Payer: Priority Health Narrow/Tiered Network	$46.87

PR F-UP/LIMITED TTHRC ECHO CONGENITAL CAR ANOMALY

Professional

Both

$337.00

Service Code	HCPCS 93304
Min. Negotiated Rate	$168.50
Max. Negotiated Rate	$252.75
Rate for Payer: Aetna Commercial	$208.46
Rate for Payer: Aetna Medicare	$168.50
Rate for Payer: BCN Commercial	$226.08
Rate for Payer: Cash Price	$269.60
Rate for Payer: Cash Price	$269.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$252.75
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$214.88
Rate for Payer: Priority Health Narrow/Tiered Network	$214.88

PR FUROSEMIDE INJECTION

Professional

Both

$4.00

Service Code	HCPCS J1940
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$3.00
Rate for Payer: Aetna Commercial	$0.59
Rate for Payer: Aetna Medicare	$2.00
Rate for Payer: BCBS Complete	$1.60
Rate for Payer: BCN Commercial	$0.10
Rate for Payer: Cash Price	$3.20
Rate for Payer: Cash Price	$3.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$3.00

PR GARAMYCIN GENTAMICIN INJ

Professional

Both

$4.00

Service Code	HCPCS J1580
Min. Negotiated Rate	$0.59
Max. Negotiated Rate	$3.00
Rate for Payer: Aetna Commercial	$2.77
Rate for Payer: Aetna Medicare	$2.00
Rate for Payer: BCBS Trust/PPO	$0.59
Rate for Payer: BCN Commercial	$0.67
Rate for Payer: Cash Price	$3.20
Rate for Payer: Cash Price	$3.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$3.00

Know your out-of-pocket cost for care.

All Charges