Bronson Lakeview Hospital

All Charges

Charge

Type

Setting

Price

PR IMG-GUIDED FLU COLLJ DRG CATH SOFT TISS PERQ

Professional

Both

$754.00

Service Code	HCPCS 10030
Min. Negotiated Rate	$127.95
Max. Negotiated Rate	$490.10
Rate for Payer: Aetna Commercial	$171.45
Rate for Payer: Aetna Medicare	$133.07
Rate for Payer: BCBS Complete	$301.60
Rate for Payer: BCBS MAPPO	$127.95
Rate for Payer: BCN Medicare Advantage	$127.95
Rate for Payer: Cash Price	$603.20
Rate for Payer: Cash Price	$603.20
Rate for Payer: Cofinity Commercial	$184.25
Rate for Payer: Cofinity Commercial	$171.45
Rate for Payer: Health Alliance Plan Medicare Advantage	$127.95
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$134.35
Rate for Payer: Nomi Health Commercial	$153.54
Rate for Payer: PACE SWMI	$127.95
Rate for Payer: PHP Medicare Advantage	$127.95
Rate for Payer: Priority Health Cigna Priority Health	$490.10
Rate for Payer: Priority Health Medicare	$129.23
Rate for Payer: UHC All Payor (Choice/PPO)	$127.95
Rate for Payer: UHC Dual Complete DSNP	$127.95
Rate for Payer: UHC Exchange	$127.95
Rate for Payer: UHC Medicare Advantage	$127.95

PR IMG-GUIDE FLUID COLLXN DRAINAG CATH PERITON PERQ

Professional

Both

$408.00

Service Code	HCPCS 49406
Min. Negotiated Rate	$163.20
Max. Negotiated Rate	$265.20
Rate for Payer: Aetna Commercial	$245.45
Rate for Payer: Aetna Medicare	$190.50
Rate for Payer: BCBS Complete	$163.20
Rate for Payer: BCBS MAPPO	$183.17
Rate for Payer: BCN Medicare Advantage	$183.17
Rate for Payer: Cash Price	$326.40
Rate for Payer: Cash Price	$326.40
Rate for Payer: Cofinity Commercial	$245.45
Rate for Payer: Cofinity Commercial	$263.76
Rate for Payer: Health Alliance Plan Medicare Advantage	$183.17
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$192.33
Rate for Payer: Nomi Health Commercial	$219.80
Rate for Payer: PACE SWMI	$183.17
Rate for Payer: PHP Medicare Advantage	$183.17
Rate for Payer: Priority Health Cigna Priority Health	$265.20
Rate for Payer: Priority Health Medicare	$185.00
Rate for Payer: UHC All Payor (Choice/PPO)	$183.17
Rate for Payer: UHC Dual Complete DSNP	$183.17
Rate for Payer: UHC Exchange	$183.17
Rate for Payer: UHC Medicare Advantage	$183.17

PRIMIDONE 50 MG TABLET

Facility

$3.57

Service Code	NDC 68084020211
Hospital Charge Code	11129
Hospital Revenue Code	637
Min. Negotiated Rate	$0.85
Max. Negotiated Rate	$3.21
Rate for Payer: Aetna Commercial	$3.03
Rate for Payer: Aetna Medicare	$0.93
Rate for Payer: Allen County Amish Medical Aid Commercial	$1.12
Rate for Payer: Amish Plain Church Group Commercial	$1.12
Rate for Payer: BCBS Complete	$1.43
Rate for Payer: BCBS MAPPO	$0.89
Rate for Payer: BCBS Trust/PPO	$2.93
Rate for Payer: BCN Commercial	$2.78
Rate for Payer: BCN Medicare Advantage	$0.89
Rate for Payer: Cash Price	$2.86
Rate for Payer: Cofinity Commercial	$3.07
Rate for Payer: Encore Health Key Benefits Commercial	$2.86
Rate for Payer: Health Alliance Plan Medicare Advantage	$0.89
Rate for Payer: Healthscope Commercial	$3.21
Rate for Payer: Lakeland Regional Health Systems Commercial	$2.68
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$0.94
Rate for Payer: MI Amish Medical Board Commercial	$1.03
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.03
Rate for Payer: Nomi Health Commercial	$2.93
Rate for Payer: PACE Senior Care Partners	$0.85
Rate for Payer: PACE SWMI	$0.89
Rate for Payer: PHP Commercial	$3.03
Rate for Payer: PHP Medicare Advantage	$0.89
Rate for Payer: Priority Health Cigna Priority Health	$2.32
Rate for Payer: Priority Health HMO/PPO	$3.11
Rate for Payer: Priority Health Medicare	$0.90
Rate for Payer: Priority Health Narrow/Tiered Network	$2.39
Rate for Payer: Railroad Medicare Medicare	$0.89
Rate for Payer: UHC All Payor (Choice/PPO)	$3.14
Rate for Payer: UHC Core	$2.98
Rate for Payer: UHC Dual Complete DSNP	$0.89
Rate for Payer: UHC Exchange	$0.89
Rate for Payer: UHC Medicare Advantage	$0.89
Rate for Payer: VA VA	$0.89
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$2.68

PRIMIDONE 50 MG TABLET

Facility

$356.16

Service Code	NDC 68084020201
Hospital Charge Code	11129
Hospital Revenue Code	637
Min. Negotiated Rate	$84.59
Max. Negotiated Rate	$320.54
Rate for Payer: Aetna Commercial	$302.74
Rate for Payer: Aetna Medicare	$92.60
Rate for Payer: Allen County Amish Medical Aid Commercial	$111.30
Rate for Payer: Amish Plain Church Group Commercial	$111.30
Rate for Payer: BCBS Complete	$142.46
Rate for Payer: BCBS MAPPO	$89.04
Rate for Payer: BCBS Trust/PPO	$292.80
Rate for Payer: BCN Commercial	$276.91
Rate for Payer: BCN Medicare Advantage	$89.04
Rate for Payer: Cash Price	$284.93
Rate for Payer: Cofinity Commercial	$306.30
Rate for Payer: Encore Health Key Benefits Commercial	$284.93
Rate for Payer: Health Alliance Plan Medicare Advantage	$89.04
Rate for Payer: Healthscope Commercial	$320.54
Rate for Payer: Lakeland Regional Health Systems Commercial	$267.12
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$93.49
Rate for Payer: MI Amish Medical Board Commercial	$102.40
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$302.74
Rate for Payer: Nomi Health Commercial	$292.05
Rate for Payer: PACE Senior Care Partners	$84.59
Rate for Payer: PACE SWMI	$89.04
Rate for Payer: PHP Commercial	$302.74
Rate for Payer: PHP Medicare Advantage	$89.04
Rate for Payer: Priority Health Cigna Priority Health	$231.50
Rate for Payer: Priority Health HMO/PPO	$309.86
Rate for Payer: Priority Health Medicare	$89.93
Rate for Payer: Priority Health Narrow/Tiered Network	$238.63
Rate for Payer: Railroad Medicare Medicare	$89.04
Rate for Payer: UHC All Payor (Choice/PPO)	$313.42
Rate for Payer: UHC Core	$297.39
Rate for Payer: UHC Dual Complete DSNP	$89.04
Rate for Payer: UHC Exchange	$89.04
Rate for Payer: UHC Medicare Advantage	$89.04
Rate for Payer: VA VA	$89.04
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$267.12

PRIMIDONE 50 MG TABLET

Facility

$3.38

Service Code	NDC 50268068611
Hospital Charge Code	11129
Hospital Revenue Code	637
Min. Negotiated Rate	$2.20
Max. Negotiated Rate	$3.04
Rate for Payer: Aetna Commercial	$2.87
Rate for Payer: BCBS Trust/PPO	$2.76
Rate for Payer: BCN Commercial	$2.61
Rate for Payer: Cash Price	$2.70
Rate for Payer: Cofinity Commercial	$2.91
Rate for Payer: Encore Health Key Benefits Commercial	$2.70
Rate for Payer: Healthscope Commercial	$3.04
Rate for Payer: Lakeland Regional Health Systems Commercial	$2.54
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.87
Rate for Payer: Nomi Health Commercial	$2.77
Rate for Payer: PHP Commercial	$2.87
Rate for Payer: Priority Health Cigna Priority Health	$2.20
Rate for Payer: Priority Health HMO/PPO	$2.94
Rate for Payer: Priority Health Narrow/Tiered Network	$2.26
Rate for Payer: UHC All Payor (Choice/PPO)	$2.97
Rate for Payer: UHC Core	$2.82
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$2.54

PRIMIDONE 50 MG TABLET

Facility

$3.38

Service Code	NDC 50268068611
Hospital Charge Code	11129
Hospital Revenue Code	637
Min. Negotiated Rate	$0.80
Max. Negotiated Rate	$3.04
Rate for Payer: Aetna Commercial	$2.87
Rate for Payer: Aetna Medicare	$0.88
Rate for Payer: Allen County Amish Medical Aid Commercial	$1.06
Rate for Payer: Amish Plain Church Group Commercial	$1.06
Rate for Payer: BCBS Complete	$1.35
Rate for Payer: BCBS MAPPO	$0.85
Rate for Payer: BCBS Trust/PPO	$2.78
Rate for Payer: BCN Commercial	$2.63
Rate for Payer: BCN Medicare Advantage	$0.85
Rate for Payer: Cash Price	$2.70
Rate for Payer: Cofinity Commercial	$2.91
Rate for Payer: Encore Health Key Benefits Commercial	$2.70
Rate for Payer: Health Alliance Plan Medicare Advantage	$0.85
Rate for Payer: Healthscope Commercial	$3.04
Rate for Payer: Lakeland Regional Health Systems Commercial	$2.54
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$0.89
Rate for Payer: MI Amish Medical Board Commercial	$0.97
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.87
Rate for Payer: Nomi Health Commercial	$2.77
Rate for Payer: PACE Senior Care Partners	$0.80
Rate for Payer: PACE SWMI	$0.85
Rate for Payer: PHP Commercial	$2.87
Rate for Payer: PHP Medicare Advantage	$0.85
Rate for Payer: Priority Health Cigna Priority Health	$2.20
Rate for Payer: Priority Health HMO/PPO	$2.94
Rate for Payer: Priority Health Medicare	$0.85
Rate for Payer: Priority Health Narrow/Tiered Network	$2.26
Rate for Payer: Railroad Medicare Medicare	$0.85
Rate for Payer: UHC All Payor (Choice/PPO)	$2.97
Rate for Payer: UHC Core	$2.82
Rate for Payer: UHC Dual Complete DSNP	$0.85
Rate for Payer: UHC Exchange	$0.85
Rate for Payer: UHC Medicare Advantage	$0.85
Rate for Payer: VA VA	$0.85
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$2.54

PRIMIDONE 50 MG TABLET

Facility

$168.63

Service Code	NDC 50268068615
Hospital Charge Code	11129
Hospital Revenue Code	637
Min. Negotiated Rate	$109.61
Max. Negotiated Rate	$151.77
Rate for Payer: Aetna Commercial	$143.34
Rate for Payer: BCBS Trust/PPO	$137.65
Rate for Payer: BCN Commercial	$130.32
Rate for Payer: Cash Price	$134.90
Rate for Payer: Cofinity Commercial	$145.02
Rate for Payer: Encore Health Key Benefits Commercial	$134.90
Rate for Payer: Healthscope Commercial	$151.77
Rate for Payer: Lakeland Regional Health Systems Commercial	$126.47
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$143.34
Rate for Payer: Nomi Health Commercial	$138.28
Rate for Payer: PHP Commercial	$143.34
Rate for Payer: Priority Health Cigna Priority Health	$109.61
Rate for Payer: Priority Health HMO/PPO	$146.71
Rate for Payer: Priority Health Narrow/Tiered Network	$112.98
Rate for Payer: UHC All Payor (Choice/PPO)	$148.39
Rate for Payer: UHC Core	$140.81
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$126.47

PRIMIDONE 50 MG TABLET

Facility

$168.63

Service Code	NDC 50268068615
Hospital Charge Code	11129
Hospital Revenue Code	637
Min. Negotiated Rate	$40.05
Max. Negotiated Rate	$151.77
Rate for Payer: Aetna Commercial	$143.34
Rate for Payer: Aetna Medicare	$43.84
Rate for Payer: Allen County Amish Medical Aid Commercial	$52.70
Rate for Payer: Amish Plain Church Group Commercial	$52.70
Rate for Payer: BCBS Complete	$67.45
Rate for Payer: BCBS MAPPO	$42.16
Rate for Payer: BCBS Trust/PPO	$138.63
Rate for Payer: BCN Commercial	$131.11
Rate for Payer: BCN Medicare Advantage	$42.16
Rate for Payer: Cash Price	$134.90
Rate for Payer: Cofinity Commercial	$145.02
Rate for Payer: Encore Health Key Benefits Commercial	$134.90
Rate for Payer: Health Alliance Plan Medicare Advantage	$42.16
Rate for Payer: Healthscope Commercial	$151.77
Rate for Payer: Lakeland Regional Health Systems Commercial	$126.47
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$44.27
Rate for Payer: MI Amish Medical Board Commercial	$48.48
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$143.34
Rate for Payer: Nomi Health Commercial	$138.28
Rate for Payer: PACE Senior Care Partners	$40.05
Rate for Payer: PACE SWMI	$42.16
Rate for Payer: PHP Commercial	$143.34
Rate for Payer: PHP Medicare Advantage	$42.16
Rate for Payer: Priority Health Cigna Priority Health	$109.61
Rate for Payer: Priority Health HMO/PPO	$146.71
Rate for Payer: Priority Health Medicare	$42.58
Rate for Payer: Priority Health Narrow/Tiered Network	$112.98
Rate for Payer: Railroad Medicare Medicare	$42.16
Rate for Payer: UHC All Payor (Choice/PPO)	$148.39
Rate for Payer: UHC Core	$140.81
Rate for Payer: UHC Dual Complete DSNP	$42.16
Rate for Payer: UHC Exchange	$42.16
Rate for Payer: UHC Medicare Advantage	$42.16
Rate for Payer: VA VA	$42.16
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$126.47

PRIMIDONE 50 MG TABLET

Facility

$356.16

Service Code	NDC 68084020201
Hospital Charge Code	11129
Hospital Revenue Code	637
Min. Negotiated Rate	$231.50
Max. Negotiated Rate	$320.54
Rate for Payer: Aetna Commercial	$302.74
Rate for Payer: BCBS Trust/PPO	$290.73
Rate for Payer: BCN Commercial	$275.24
Rate for Payer: Cash Price	$284.93
Rate for Payer: Cofinity Commercial	$306.30
Rate for Payer: Encore Health Key Benefits Commercial	$284.93
Rate for Payer: Healthscope Commercial	$320.54
Rate for Payer: Lakeland Regional Health Systems Commercial	$267.12
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$302.74
Rate for Payer: Nomi Health Commercial	$292.05
Rate for Payer: PHP Commercial	$302.74
Rate for Payer: Priority Health Cigna Priority Health	$231.50
Rate for Payer: Priority Health HMO/PPO	$309.86
Rate for Payer: Priority Health Narrow/Tiered Network	$238.63
Rate for Payer: UHC All Payor (Choice/PPO)	$313.42
Rate for Payer: UHC Core	$297.39
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$267.12

PRIMIDONE 50 MG TABLET

Facility

$3.57

Service Code	NDC 68084020211
Hospital Charge Code	11129
Hospital Revenue Code	637
Min. Negotiated Rate	$2.32
Max. Negotiated Rate	$3.21
Rate for Payer: Aetna Commercial	$3.03
Rate for Payer: BCBS Trust/PPO	$2.91
Rate for Payer: BCN Commercial	$2.76
Rate for Payer: Cash Price	$2.86
Rate for Payer: Cofinity Commercial	$3.07
Rate for Payer: Encore Health Key Benefits Commercial	$2.86
Rate for Payer: Healthscope Commercial	$3.21
Rate for Payer: Lakeland Regional Health Systems Commercial	$2.68
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.03
Rate for Payer: Nomi Health Commercial	$2.93
Rate for Payer: PHP Commercial	$3.03
Rate for Payer: Priority Health Cigna Priority Health	$2.32
Rate for Payer: Priority Health HMO/PPO	$3.11
Rate for Payer: Priority Health Narrow/Tiered Network	$2.39
Rate for Payer: UHC All Payor (Choice/PPO)	$3.14
Rate for Payer: UHC Core	$2.98
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$2.68

PR IMM ADMN SARSCOV2 100 MCG/0.5 ML 1ST DOSE

Professional

Both

$41.00

Service Code	HCPCS 0011A
Min. Negotiated Rate	$16.40
Max. Negotiated Rate	$26.65
Rate for Payer: Aetna Medicare	$20.50
Rate for Payer: BCBS Complete	$16.40
Rate for Payer: Cash Price	$32.80
Rate for Payer: Priority Health Cigna Priority Health	$26.65

PR IMM ADMN SARSCOV2 100 MCG/0.5 ML 2ND DOSE

Professional

Both

$41.00

Service Code	HCPCS 0012A
Min. Negotiated Rate	$16.40
Max. Negotiated Rate	$26.65
Rate for Payer: Aetna Medicare	$20.50
Rate for Payer: BCBS Complete	$16.40
Rate for Payer: Cash Price	$32.80
Rate for Payer: Priority Health Cigna Priority Health	$26.65

PR IMM ADMN SARSCOV2 100 MCG/0.5 ML 3RD DOSE

Professional

Both

$41.00

Service Code	HCPCS 0013A
Min. Negotiated Rate	$16.40
Max. Negotiated Rate	$26.65
Rate for Payer: Aetna Medicare	$20.50
Rate for Payer: BCBS Complete	$16.40
Rate for Payer: Cash Price	$32.80
Rate for Payer: Priority Health Cigna Priority Health	$26.65

PR IMM ADMN SARSCOV2 10MCG/0.2ML TRIS-SUCROSE 1ST

Professional

Both

$41.00

Service Code	HCPCS 0071A
Min. Negotiated Rate	$16.40
Max. Negotiated Rate	$26.65
Rate for Payer: Aetna Medicare	$20.50
Rate for Payer: BCBS Complete	$16.40
Rate for Payer: Cash Price	$32.80
Rate for Payer: Priority Health Cigna Priority Health	$26.65

PR IMM ADMN SARSCOV2 10MCG/0.2ML TRIS-SUCROSE 2ND

Professional

Both

$41.00

Service Code	HCPCS 0072A
Min. Negotiated Rate	$16.40
Max. Negotiated Rate	$26.65
Rate for Payer: Aetna Medicare	$20.50
Rate for Payer: BCBS Complete	$16.40
Rate for Payer: Cash Price	$32.80
Rate for Payer: Priority Health Cigna Priority Health	$26.65

PR IMM ADMN SARSCOV2 10MCG/0.2ML TRIS-SUCROSE 3RD

Professional

Both

$41.00

Service Code	HCPCS 0073A
Min. Negotiated Rate	$16.40
Max. Negotiated Rate	$26.65
Rate for Payer: Aetna Medicare	$20.50
Rate for Payer: BCBS Complete	$16.40
Rate for Payer: Cash Price	$32.80
Rate for Payer: Priority Health Cigna Priority Health	$26.65

PR IMM ADMN SARSCOV2 10MCG/0.2ML TRIS-SUCROSE BST

Professional

Both

$41.00

Service Code	HCPCS 0074A
Min. Negotiated Rate	$16.40
Max. Negotiated Rate	$26.65
Rate for Payer: Aetna Medicare	$20.50
Rate for Payer: BCBS Complete	$16.40
Rate for Payer: Cash Price	$32.80
Rate for Payer: Priority Health Cigna Priority Health	$26.65

PR IMM ADMN SARSCOV2 25 MCG/0.25 ML 1ST DOSE

Professional

Both

$41.00

Service Code	HCPCS 0111A
Min. Negotiated Rate	$16.40
Max. Negotiated Rate	$26.65
Rate for Payer: Aetna Medicare	$20.50
Rate for Payer: BCBS Complete	$16.40
Rate for Payer: Cash Price	$32.80
Rate for Payer: Priority Health Cigna Priority Health	$26.65

PR IMM ADMN SARSCOV2 25 MCG/0.25 ML 2ND DOSE

Professional

Both

$41.00

Service Code	HCPCS 0112A
Min. Negotiated Rate	$16.40
Max. Negotiated Rate	$26.65
Rate for Payer: Aetna Medicare	$20.50
Rate for Payer: BCBS Complete	$16.40
Rate for Payer: Cash Price	$32.80
Rate for Payer: Priority Health Cigna Priority Health	$26.65

PR IMM ADMN SARSCOV2 30MCG/0.3ML DIL RECON 1ST DOSE

Professional

Both

$41.00

Service Code	HCPCS 0001A
Min. Negotiated Rate	$16.40
Max. Negotiated Rate	$26.65
Rate for Payer: Aetna Medicare	$20.50
Rate for Payer: BCBS Complete	$16.40
Rate for Payer: Cash Price	$32.80
Rate for Payer: Priority Health Cigna Priority Health	$26.65

PR IMM ADMN SARSCOV2 30MCG/0.3ML DIL RECON 2ND DOSE

Professional

Both

$41.00

Service Code	HCPCS 0002A
Min. Negotiated Rate	$16.40
Max. Negotiated Rate	$26.65
Rate for Payer: Aetna Medicare	$20.50
Rate for Payer: BCBS Complete	$16.40
Rate for Payer: Cash Price	$32.80
Rate for Payer: Priority Health Cigna Priority Health	$26.65

PR IMM ADMN SARSCOV2 30MCG/0.3ML DIL RECON 3RD DOSE

Professional

Both

$41.00

Service Code	HCPCS 0003A
Min. Negotiated Rate	$16.40
Max. Negotiated Rate	$26.65
Rate for Payer: Aetna Medicare	$20.50
Rate for Payer: BCBS Complete	$16.40
Rate for Payer: Cash Price	$32.80
Rate for Payer: Priority Health Cigna Priority Health	$26.65

PR IMM ADMN SARSCOV2 30MCG/0.3ML DIL RECON BST DOSE

Professional

Both

$41.00

Service Code	HCPCS 0004A
Min. Negotiated Rate	$16.40
Max. Negotiated Rate	$26.65
Rate for Payer: Aetna Medicare	$20.50
Rate for Payer: BCBS Complete	$16.40
Rate for Payer: Cash Price	$32.80
Rate for Payer: Priority Health Cigna Priority Health	$26.65

PR IMM ADMN SARSCOV2 30MCG/0.3ML TRIS-SUCROSE 1ST

Professional

Both

$41.00

Service Code	HCPCS 0051A
Min. Negotiated Rate	$16.40
Max. Negotiated Rate	$26.65
Rate for Payer: Aetna Medicare	$20.50
Rate for Payer: BCBS Complete	$16.40
Rate for Payer: Cash Price	$32.80
Rate for Payer: Priority Health Cigna Priority Health	$26.65

PR IMM ADMN SARSCOV2 30MCG/0.3ML TRIS-SUCROSE 2ND

Professional

Both

$41.00

Service Code	HCPCS 0052A
Min. Negotiated Rate	$16.40
Max. Negotiated Rate	$26.65
Rate for Payer: Aetna Medicare	$20.50
Rate for Payer: BCBS Complete	$16.40
Rate for Payer: Cash Price	$32.80
Rate for Payer: Priority Health Cigna Priority Health	$26.65

Know your out-of-pocket cost for care.

All Charges