Bronson Lakeview Hospital

All Charges

Charge

Type

Setting

Price

PR REVJ OPN ARVEN FSTL W/O THRMBC DIAL GRF

Professional

Both

$1,261.00

Service Code	HCPCS 36832
Min. Negotiated Rate	$438.99
Max. Negotiated Rate	$1,191.52
Rate for Payer: Aetna Commercial	$1,014.04
Rate for Payer: Aetna Medicare	$630.50
Rate for Payer: BCBS Complete	$460.94
Rate for Payer: BCN Commercial	$1,108.01
Rate for Payer: Cash Price	$1,008.80
Rate for Payer: Cash Price	$1,008.80
Rate for Payer: Mclaren Medicaid	$438.99
Rate for Payer: Meridian Medicaid	$460.94
Rate for Payer: Opus (Opus Packaging Group) HMA	$945.75
Rate for Payer: Priority Health Choice Medicaid	$438.99
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$1,191.52
Rate for Payer: Priority Health Narrow/Tiered Network	$1,191.52
Rate for Payer: UHC Medicaid	$438.99
Rate for Payer: UHCCP Medicaid	$438.99

PR REVJ OPN ARVEN FSTL W/THRMBC DIAL GRF

Professional

Both

$2,403.00

Service Code	HCPCS 36833
Min. Negotiated Rate	$469.67
Max. Negotiated Rate	$1,802.25
Rate for Payer: Aetna Commercial	$1,085.98
Rate for Payer: Aetna Medicare	$1,201.50
Rate for Payer: BCBS Complete	$493.15
Rate for Payer: BCN Commercial	$1,182.20
Rate for Payer: Cash Price	$1,922.40
Rate for Payer: Cash Price	$1,922.40
Rate for Payer: Mclaren Medicaid	$469.67
Rate for Payer: Meridian Medicaid	$493.15
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,802.25
Rate for Payer: Priority Health Choice Medicaid	$469.67
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$1,271.32
Rate for Payer: Priority Health Narrow/Tiered Network	$1,271.32
Rate for Payer: UHC Medicaid	$469.67
Rate for Payer: UHCCP Medicaid	$469.67

PR REVJ/RMVL IMPL SPI NPG/RCVR DTCH CONNJ ELTRD RA

Professional

Both

$1,874.00

Service Code	HCPCS 63688
Min. Negotiated Rate	$194.90
Max. Negotiated Rate	$1,405.50
Rate for Payer: Aetna Commercial	$478.21
Rate for Payer: Aetna Medicare	$937.00
Rate for Payer: BCBS Complete	$204.65
Rate for Payer: BCN Commercial	$453.17
Rate for Payer: Cash Price	$1,499.20
Rate for Payer: Cash Price	$1,499.20
Rate for Payer: Mclaren Medicaid	$194.90
Rate for Payer: Meridian Medicaid	$204.65
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,405.50
Rate for Payer: Priority Health Choice Medicaid	$194.90
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$526.33
Rate for Payer: Priority Health Narrow/Tiered Network	$526.33
Rate for Payer: UHC Medicaid	$194.90
Rate for Payer: UHCCP Medicaid	$194.90

PR REVJ/RMVL INTRACRANIAL NEUROSTIMULATOR ELTRDS

Professional

Both

$3,280.00

Service Code	HCPCS 61880
Min. Negotiated Rate	$395.12
Max. Negotiated Rate	$2,460.00
Rate for Payer: Aetna Commercial	$745.42
Rate for Payer: Aetna Medicare	$1,640.00
Rate for Payer: BCBS Complete	$414.88
Rate for Payer: BCN Commercial	$904.83
Rate for Payer: Cash Price	$2,624.00
Rate for Payer: Cash Price	$2,624.00
Rate for Payer: Mclaren Medicaid	$395.12
Rate for Payer: Meridian Medicaid	$414.88
Rate for Payer: Opus (Opus Packaging Group) HMA	$2,460.00
Rate for Payer: Priority Health Choice Medicaid	$395.12
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$1,050.95
Rate for Payer: Priority Health Narrow/Tiered Network	$1,050.95
Rate for Payer: UHC Medicaid	$395.12
Rate for Payer: UHCCP Medicaid	$395.12

PR REVJ/RMVL NEUROSTIMULATOR PULSE GENERATOR

Professional

Both

$1,079.00

Service Code	HCPCS 61888
Min. Negotiated Rate	$257.09
Max. Negotiated Rate	$840.01
Rate for Payer: Aetna Commercial	$512.47
Rate for Payer: Aetna Medicare	$539.50
Rate for Payer: BCBS Complete	$269.94
Rate for Payer: BCN Commercial	$840.01
Rate for Payer: Cash Price	$863.20
Rate for Payer: Cash Price	$863.20
Rate for Payer: Mclaren Medicaid	$257.09
Rate for Payer: Meridian Medicaid	$269.94
Rate for Payer: Opus (Opus Packaging Group) HMA	$809.25
Rate for Payer: Priority Health Choice Medicaid	$257.09
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$706.22
Rate for Payer: Priority Health Narrow/Tiered Network	$706.22
Rate for Payer: UHC Medicaid	$257.09
Rate for Payer: UHCCP Medicaid	$257.09

PR REVJ/RMVL PERPH NEUROSTIMULATOR ELECTRODE ARRAY

Professional

Both

$1,378.00

Service Code	HCPCS 64585
Min. Negotiated Rate	$86.69
Max. Negotiated Rate	$1,033.50
Rate for Payer: Aetna Commercial	$182.91
Rate for Payer: Aetna Medicare	$689.00
Rate for Payer: BCBS Complete	$91.02
Rate for Payer: BCN Commercial	$216.62
Rate for Payer: Cash Price	$1,102.40
Rate for Payer: Cash Price	$1,102.40
Rate for Payer: Mclaren Medicaid	$86.69
Rate for Payer: Meridian Medicaid	$91.02
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,033.50
Rate for Payer: Priority Health Choice Medicaid	$86.69
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$251.61
Rate for Payer: Priority Health Narrow/Tiered Network	$251.61
Rate for Payer: UHC Medicaid	$86.69
Rate for Payer: UHCCP Medicaid	$86.69

PR REVJ/RMVL PROSTHETIC VAGINAL GRAFT VAGINAL APP

Professional

Both

$1,463.00

Service Code	HCPCS 57295
Min. Negotiated Rate	$286.06
Max. Negotiated Rate	$1,097.25
Rate for Payer: Aetna Commercial	$593.12
Rate for Payer: Aetna Medicare	$731.50
Rate for Payer: BCBS Complete	$300.36
Rate for Payer: BCN Commercial	$1,041.59
Rate for Payer: Cash Price	$1,170.40
Rate for Payer: Cash Price	$1,170.40
Rate for Payer: Mclaren Medicaid	$286.06
Rate for Payer: Meridian Medicaid	$300.36
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,097.25
Rate for Payer: Priority Health Choice Medicaid	$286.06
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$763.59
Rate for Payer: Priority Health Narrow/Tiered Network	$763.59
Rate for Payer: UHC Medicaid	$286.06
Rate for Payer: UHCCP Medicaid	$286.06

PR REVJ/RPLCMT HPGLSL NERVE NSTIM RA PG&RESPIR SNR

Professional

Both

$1,807.00

Service Code	HCPCS 64583
Min. Negotiated Rate	$475.20
Max. Negotiated Rate	$1,506.73
Rate for Payer: Aetna Commercial	$1,017.89
Rate for Payer: Aetna Medicare	$903.50
Rate for Payer: BCBS Complete	$498.96
Rate for Payer: BCN Commercial	$1,297.24
Rate for Payer: Cash Price	$1,445.60
Rate for Payer: Cash Price	$1,445.60
Rate for Payer: Mclaren Medicaid	$475.20
Rate for Payer: Meridian Medicaid	$498.96
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,355.25
Rate for Payer: Priority Health Choice Medicaid	$475.20
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$1,506.73
Rate for Payer: Priority Health Narrow/Tiered Network	$1,506.73
Rate for Payer: UHC Medicaid	$475.20
Rate for Payer: UHCCP Medicaid	$475.20

PR REVJ/RPLMNT CH WAL RESPIR ELTRD & CONJ PULSE GEN

Professional

Both

$840.00

Service Code	HCPCS 0467T
Min. Negotiated Rate	$336.00
Max. Negotiated Rate	$630.00
Rate for Payer: Aetna Medicare	$420.00
Rate for Payer: BCBS Complete	$336.00
Rate for Payer: Cash Price	$672.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$630.00

PR REVJ TOTAL KNEE ARTHRP W/WO ALGRFT 1 COMPONENT

Professional

Both

$4,705.00

Service Code	HCPCS 27486
Min. Negotiated Rate	$813.02
Max. Negotiated Rate	$3,528.75
Rate for Payer: Aetna Commercial	$1,879.07
Rate for Payer: Aetna Medicare	$2,352.50
Rate for Payer: BCBS Complete	$853.67
Rate for Payer: BCN Commercial	$2,121.40
Rate for Payer: Cash Price	$3,764.00
Rate for Payer: Cash Price	$3,764.00
Rate for Payer: Mclaren Medicaid	$813.02
Rate for Payer: Meridian Medicaid	$853.67
Rate for Payer: Opus (Opus Packaging Group) HMA	$3,528.75
Rate for Payer: Priority Health Choice Medicaid	$813.02
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$2,267.71
Rate for Payer: Priority Health Narrow/Tiered Network	$2,267.71
Rate for Payer: UHC Medicaid	$813.02
Rate for Payer: UHCCP Medicaid	$813.02

PR REVJ TOT HIP ARTHRP ACTBLR W/WO AGRFT/ALGRFT

Professional

Both

$3,129.00

Service Code	HCPCS 27137
Min. Negotiated Rate	$840.29
Max. Negotiated Rate	$2,360.33
Rate for Payer: Aetna Commercial	$1,964.36
Rate for Payer: Aetna Medicare	$1,564.50
Rate for Payer: BCBS Complete	$882.30
Rate for Payer: BCN Commercial	$2,208.05
Rate for Payer: Cash Price	$2,503.20
Rate for Payer: Cash Price	$2,503.20
Rate for Payer: Mclaren Medicaid	$840.29
Rate for Payer: Meridian Medicaid	$882.30
Rate for Payer: Opus (Opus Packaging Group) HMA	$2,346.75
Rate for Payer: Priority Health Choice Medicaid	$840.29
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$2,360.33
Rate for Payer: Priority Health Narrow/Tiered Network	$2,360.33
Rate for Payer: UHC Medicaid	$840.29
Rate for Payer: UHCCP Medicaid	$840.29

PR REVJ TOT HIP ARTHRP BTH W/WO AGRFT/ALGRFT

Professional

Both

$4,077.00

Service Code	HCPCS 27134
Min. Negotiated Rate	$1,081.19
Max. Negotiated Rate	$3,143.45
Rate for Payer: Aetna Commercial	$2,555.78
Rate for Payer: Aetna Medicare	$2,038.50
Rate for Payer: BCBS Complete	$1,135.25
Rate for Payer: BCN Commercial	$3,143.45
Rate for Payer: Cash Price	$3,261.60
Rate for Payer: Cash Price	$3,261.60
Rate for Payer: Mclaren Medicaid	$1,081.19
Rate for Payer: Meridian Medicaid	$1,135.25
Rate for Payer: Opus (Opus Packaging Group) HMA	$3,057.75
Rate for Payer: Priority Health Choice Medicaid	$1,081.19
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$3,058.76
Rate for Payer: Priority Health Narrow/Tiered Network	$3,058.76
Rate for Payer: UHC Medicaid	$1,081.19
Rate for Payer: UHCCP Medicaid	$1,081.19

PR REVJ TOT HIP ARTHRP FEM ONLY W/WO ALGRFT

Professional

Both

$3,252.00

Service Code	HCPCS 27138
Min. Negotiated Rate	$871.81
Max. Negotiated Rate	$2,451.38
Rate for Payer: Aetna Commercial	$2,041.22
Rate for Payer: Aetna Medicare	$1,626.00
Rate for Payer: BCBS Complete	$915.40
Rate for Payer: BCN Commercial	$2,293.20
Rate for Payer: Cash Price	$2,601.60
Rate for Payer: Cash Price	$2,601.60
Rate for Payer: Mclaren Medicaid	$871.81
Rate for Payer: Meridian Medicaid	$915.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$2,439.00
Rate for Payer: Priority Health Choice Medicaid	$871.81
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$2,451.38
Rate for Payer: Priority Health Narrow/Tiered Network	$2,451.38
Rate for Payer: UHC Medicaid	$871.81
Rate for Payer: UHCCP Medicaid	$871.81

PR REVJ TOT KNEE ARTHRP FEM&ENTIRE TIBIAL COMPONE

Professional

Both

$6,183.00

Service Code	HCPCS 27487
Min. Negotiated Rate	$1,004.08
Max. Negotiated Rate	$4,637.25
Rate for Payer: Aetna Commercial	$2,348.25
Rate for Payer: Aetna Medicare	$3,091.50
Rate for Payer: BCBS Complete	$1,054.28
Rate for Payer: BCN Commercial	$2,899.46
Rate for Payer: Cash Price	$4,946.40
Rate for Payer: Cash Price	$4,946.40
Rate for Payer: Mclaren Medicaid	$1,004.08
Rate for Payer: Meridian Medicaid	$1,054.28
Rate for Payer: Opus (Opus Packaging Group) HMA	$4,637.25
Rate for Payer: Priority Health Choice Medicaid	$1,004.08
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$2,821.33
Rate for Payer: Priority Health Narrow/Tiered Network	$2,821.33
Rate for Payer: UHC Medicaid	$1,004.08
Rate for Payer: UHCCP Medicaid	$1,004.08

PR REVJ UR-CUTAN ANAST RPR FSCAL DFCT & HERNIA

Professional

Both

$1,478.00

Service Code	HCPCS 50728
Min. Negotiated Rate	$406.19
Max. Negotiated Rate	$1,144.60
Rate for Payer: Aetna Commercial	$942.32
Rate for Payer: Aetna Medicare	$739.00
Rate for Payer: BCBS Complete	$426.50
Rate for Payer: BCN Commercial	$1,050.74
Rate for Payer: Cash Price	$1,182.40
Rate for Payer: Cash Price	$1,182.40
Rate for Payer: Mclaren Medicaid	$406.19
Rate for Payer: Meridian Medicaid	$426.50
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,108.50
Rate for Payer: Priority Health Choice Medicaid	$406.19
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$1,144.60
Rate for Payer: Priority Health Narrow/Tiered Network	$1,144.60
Rate for Payer: UHC Medicaid	$406.19
Rate for Payer: UHCCP Medicaid	$406.19

PR REVJ URINARY-CUTANEOUS ANASTAMOSIS

Professional

Both

$1,335.00

Service Code	HCPCS 50727
Min. Negotiated Rate	$302.03
Max. Negotiated Rate	$1,001.25
Rate for Payer: Aetna Commercial	$652.33
Rate for Payer: Aetna Medicare	$667.50
Rate for Payer: BCBS Complete	$317.13
Rate for Payer: BCN Commercial	$768.38
Rate for Payer: Cash Price	$1,068.00
Rate for Payer: Cash Price	$1,068.00
Rate for Payer: Mclaren Medicaid	$302.03
Rate for Payer: Meridian Medicaid	$317.13
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,001.25
Rate for Payer: Priority Health Choice Medicaid	$302.03
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$837.03
Rate for Payer: Priority Health Narrow/Tiered Network	$837.03
Rate for Payer: UHC Medicaid	$302.03
Rate for Payer: UHCCP Medicaid	$302.03

PR REV/RMV PRPH SAC/GSTRC NPG/RCV DTCH CONN ELTR RA

Professional

Both

$717.00

Service Code	HCPCS 64595
Min. Negotiated Rate	$133.76
Max. Negotiated Rate	$537.75
Rate for Payer: Aetna Commercial	$161.68
Rate for Payer: Aetna Medicare	$358.50
Rate for Payer: BCBS Complete	$140.45
Rate for Payer: BCN Commercial	$345.59
Rate for Payer: Cash Price	$573.60
Rate for Payer: Cash Price	$573.60
Rate for Payer: Mclaren Medicaid	$133.76
Rate for Payer: Meridian Medicaid	$140.45
Rate for Payer: Opus (Opus Packaging Group) HMA	$537.75
Rate for Payer: Priority Health Choice Medicaid	$133.76
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$401.40
Rate for Payer: Priority Health Narrow/Tiered Network	$401.40
Rate for Payer: UHC Medicaid	$133.76
Rate for Payer: UHCCP Medicaid	$133.76

PR REVSC EVASC FPVT ANGIOP UNI CPLX LES 1ST VSL

Professional

Both

$1,220.00

Service Code	HCPCS 37265
Min. Negotiated Rate	$307.15
Max. Negotiated Rate	$915.00
Rate for Payer: Aetna Medicare	$610.00
Rate for Payer: BCBS Complete	$322.51
Rate for Payer: Cash Price	$976.00
Rate for Payer: Cash Price	$976.00
Rate for Payer: Mclaren Medicaid	$307.15
Rate for Payer: Meridian Medicaid	$322.51
Rate for Payer: Opus (Opus Packaging Group) HMA	$915.00
Rate for Payer: Priority Health Choice Medicaid	$307.15
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$709.67
Rate for Payer: Priority Health Narrow/Tiered Network	$709.67
Rate for Payer: UHC Medicaid	$307.15
Rate for Payer: UHCCP Medicaid	$307.15

PR REVSC EVASC FPVT ANGIOP UNI SF LES 1ST VSL

Professional

Both

$902.00

Service Code	HCPCS 37263
Min. Negotiated Rate	$227.06
Max. Negotiated Rate	$676.50
Rate for Payer: Aetna Medicare	$451.00
Rate for Payer: BCBS Complete	$238.41
Rate for Payer: Cash Price	$721.60
Rate for Payer: Cash Price	$721.60
Rate for Payer: Mclaren Medicaid	$227.06
Rate for Payer: Meridian Medicaid	$238.41
Rate for Payer: Opus (Opus Packaging Group) HMA	$676.50
Rate for Payer: Priority Health Choice Medicaid	$227.06
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$524.99
Rate for Payer: Priority Health Narrow/Tiered Network	$524.99
Rate for Payer: UHC Medicaid	$227.06
Rate for Payer: UHCCP Medicaid	$227.06

PR REVSC EVASC FPVT ATHRC UNI CPLX LES 1ST VSL

Professional

Both

$1,458.00

Service Code	HCPCS 37273
Min. Negotiated Rate	$367.43
Max. Negotiated Rate	$1,093.50
Rate for Payer: Aetna Medicare	$729.00
Rate for Payer: BCBS Complete	$385.80
Rate for Payer: Cash Price	$1,166.40
Rate for Payer: Cash Price	$1,166.40
Rate for Payer: Mclaren Medicaid	$367.43
Rate for Payer: Meridian Medicaid	$385.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,093.50
Rate for Payer: Priority Health Choice Medicaid	$367.43
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$849.04
Rate for Payer: Priority Health Narrow/Tiered Network	$849.04
Rate for Payer: UHC Medicaid	$367.43
Rate for Payer: UHCCP Medicaid	$367.43

PR REVSC EVASC FPVT ATHRC UNI SF LES 1ST VSL

Professional

Both

$776.00

Service Code	HCPCS 37271
Min. Negotiated Rate	$262.42
Max. Negotiated Rate	$606.74
Rate for Payer: Aetna Medicare	$388.00
Rate for Payer: BCBS Complete	$275.54
Rate for Payer: Cash Price	$620.80
Rate for Payer: Cash Price	$620.80
Rate for Payer: Mclaren Medicaid	$262.42
Rate for Payer: Meridian Medicaid	$275.54
Rate for Payer: Opus (Opus Packaging Group) HMA	$582.00
Rate for Payer: Priority Health Choice Medicaid	$262.42
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$606.74
Rate for Payer: Priority Health Narrow/Tiered Network	$606.74
Rate for Payer: UHC Medicaid	$262.42
Rate for Payer: UHCCP Medicaid	$262.42

PR REVSC EVASC FPVT ST PLMT UNI SF LES 1ST VSL

Professional

Both

$9,832.00

Service Code	HCPCS 37267
Min. Negotiated Rate	$256.03
Max. Negotiated Rate	$7,374.00
Rate for Payer: Aetna Medicare	$4,916.00
Rate for Payer: BCBS Complete	$268.83
Rate for Payer: Cash Price	$7,865.60
Rate for Payer: Cash Price	$7,865.60
Rate for Payer: Mclaren Medicaid	$256.03
Rate for Payer: Meridian Medicaid	$268.83
Rate for Payer: Opus (Opus Packaging Group) HMA	$7,374.00
Rate for Payer: Priority Health Choice Medicaid	$256.03
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$591.97
Rate for Payer: Priority Health Narrow/Tiered Network	$591.97
Rate for Payer: UHC Medicaid	$256.03
Rate for Payer: UHCCP Medicaid	$256.03

PR REVSC EVASC IMVT ANGIOP UNI SF LES 1ST VSL

Professional

Both

$946.00

Service Code	HCPCS 37296
Min. Negotiated Rate	$319.71
Max. Negotiated Rate	$739.22
Rate for Payer: Aetna Medicare	$473.00
Rate for Payer: BCBS Complete	$335.70
Rate for Payer: Cash Price	$756.80
Rate for Payer: Cash Price	$756.80
Rate for Payer: Mclaren Medicaid	$319.71
Rate for Payer: Meridian Medicaid	$335.70
Rate for Payer: Opus (Opus Packaging Group) HMA	$709.50
Rate for Payer: Priority Health Choice Medicaid	$319.71
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$739.22
Rate for Payer: Priority Health Narrow/Tiered Network	$739.22
Rate for Payer: UHC Medicaid	$319.71
Rate for Payer: UHCCP Medicaid	$319.71

PR REVSC EVASC IVT ANGIOP UNI SF LES 1ST VSL

Professional

Both

$633.00

Service Code	HCPCS 37254
Min. Negotiated Rate	$214.07
Max. Negotiated Rate	$494.95
Rate for Payer: Aetna Medicare	$316.50
Rate for Payer: BCBS Complete	$224.77
Rate for Payer: Cash Price	$506.40
Rate for Payer: Cash Price	$506.40
Rate for Payer: Mclaren Medicaid	$214.07
Rate for Payer: Meridian Medicaid	$224.77
Rate for Payer: Opus (Opus Packaging Group) HMA	$474.75
Rate for Payer: Priority Health Choice Medicaid	$214.07
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$494.95
Rate for Payer: Priority Health Narrow/Tiered Network	$494.95
Rate for Payer: UHC Medicaid	$214.07
Rate for Payer: UHCCP Medicaid	$214.07

PR REVSC EVASC IVT ANGIOP UNI SF LES EA ADDL VSL

Professional

Both

$256.00

Service Code	HCPCS 37255
Min. Negotiated Rate	$86.69
Max. Negotiated Rate	$200.44
Rate for Payer: Aetna Medicare	$128.00
Rate for Payer: BCBS Complete	$91.02
Rate for Payer: Cash Price	$204.80
Rate for Payer: Cash Price	$204.80
Rate for Payer: Mclaren Medicaid	$86.69
Rate for Payer: Meridian Medicaid	$91.02
Rate for Payer: Opus (Opus Packaging Group) HMA	$192.00
Rate for Payer: Priority Health Choice Medicaid	$86.69
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$200.44
Rate for Payer: Priority Health Narrow/Tiered Network	$200.44
Rate for Payer: UHC Medicaid	$86.69
Rate for Payer: UHCCP Medicaid	$86.69

Know your out-of-pocket cost for care.

All Charges