|
HC HOLTER SCAN
|
Facility
|
OP
|
$1,033.01
|
|
|
Service Code
|
CPT 93226
|
| Hospital Charge Code |
73100003
|
|
Hospital Revenue Code
|
731
|
| Min. Negotiated Rate |
$29.77 |
| Max. Negotiated Rate |
$929.71 |
| Rate for Payer: Aetna Commercial |
$878.06
|
| Rate for Payer: Aetna Medicare |
$56.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$671.46
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$68.04
|
| Rate for Payer: Amish Plain Church Group Commercial |
$68.04
|
| Rate for Payer: BCBS Complete |
$31.26
|
| Rate for Payer: BCBS MAPPO |
$54.43
|
| Rate for Payer: BCBS Trust/PPO |
$164.26
|
| Rate for Payer: BCN Medicare Advantage |
$54.43
|
| Rate for Payer: Cash Price |
$826.41
|
| Rate for Payer: Cash Price |
$826.41
|
| Rate for Payer: Cofinity Commercial |
$888.39
|
| Rate for Payer: Cofinity Commercial |
$723.11
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$54.43
|
| Rate for Payer: Healthscope Commercial |
$929.71
|
| Rate for Payer: Mclaren Medicaid |
$29.77
|
| Rate for Payer: Mclaren Medicare |
$54.43
|
| Rate for Payer: Meridian Medicaid |
$31.26
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$57.15
|
| Rate for Payer: MI Amish Medical Board Commercial |
$62.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$878.06
|
| Rate for Payer: PACE Medicare |
$51.71
|
| Rate for Payer: PACE SWMI |
$54.43
|
| Rate for Payer: PHP Commercial |
$878.06
|
| Rate for Payer: PHP Medicare Advantage |
$54.43
|
| Rate for Payer: Priority Health Choice Medicaid |
$29.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$723.11
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$351.10
|
| Rate for Payer: Priority Health Medicare |
$54.43
|
| Rate for Payer: Priority Health Narrow Network |
$280.88
|
| Rate for Payer: Priority Health SBD |
$650.80
|
| Rate for Payer: Railroad Medicare Medicare |
$54.43
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$38.54
|
| Rate for Payer: UHC Dual Complete DSNP |
$54.43
|
| Rate for Payer: UHC Exchange |
$35.04
|
| Rate for Payer: UHC Medicare Advantage |
$56.06
|
| Rate for Payer: VA VA |
$54.43
|
|
|
HC HOME SLEEP TEST TYPE 3 PORTA
|
Facility
|
OP
|
$208.01
|
|
|
Service Code
|
HCPCS G0399
|
| Hospital Charge Code |
92000027
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$76.03 |
| Max. Negotiated Rate |
$436.07 |
| Rate for Payer: Aetna Commercial |
$176.81
|
| Rate for Payer: Aetna Medicare |
$144.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$135.21
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$173.74
|
| Rate for Payer: Amish Plain Church Group Commercial |
$173.74
|
| Rate for Payer: BCBS Complete |
$79.84
|
| Rate for Payer: BCBS MAPPO |
$138.99
|
| Rate for Payer: BCBS Trust/PPO |
$422.58
|
| Rate for Payer: BCN Medicare Advantage |
$138.99
|
| Rate for Payer: Cash Price |
$166.41
|
| Rate for Payer: Cash Price |
$166.41
|
| Rate for Payer: Cofinity Commercial |
$145.61
|
| Rate for Payer: Cofinity Commercial |
$178.89
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$138.99
|
| Rate for Payer: Healthscope Commercial |
$187.21
|
| Rate for Payer: Mclaren Medicaid |
$76.03
|
| Rate for Payer: Mclaren Medicare |
$138.99
|
| Rate for Payer: Meridian Medicaid |
$79.84
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$145.94
|
| Rate for Payer: MI Amish Medical Board Commercial |
$159.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$176.81
|
| Rate for Payer: PACE Medicare |
$132.04
|
| Rate for Payer: PACE SWMI |
$138.99
|
| Rate for Payer: PHP Commercial |
$176.81
|
| Rate for Payer: PHP Medicare Advantage |
$138.99
|
| Rate for Payer: Priority Health Choice Medicaid |
$76.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$145.61
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$436.07
|
| Rate for Payer: Priority Health Medicare |
$138.99
|
| Rate for Payer: Priority Health Narrow Network |
$348.85
|
| Rate for Payer: Priority Health SBD |
$131.05
|
| Rate for Payer: Railroad Medicare Medicare |
$138.99
|
| Rate for Payer: UHC Dual Complete DSNP |
$138.99
|
| Rate for Payer: UHC Medicare Advantage |
$143.16
|
| Rate for Payer: VA VA |
$138.99
|
|
|
HC HOME SLEEP TEST TYPE 3 PORTA
|
Facility
|
IP
|
$208.01
|
|
|
Service Code
|
HCPCS G0399
|
| Hospital Charge Code |
92000027
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$131.05 |
| Max. Negotiated Rate |
$187.21 |
| Rate for Payer: Aetna Commercial |
$176.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$135.21
|
| Rate for Payer: Cash Price |
$166.41
|
| Rate for Payer: Cofinity Commercial |
$145.61
|
| Rate for Payer: Cofinity Commercial |
$178.89
|
| Rate for Payer: Healthscope Commercial |
$187.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$176.81
|
| Rate for Payer: PHP Commercial |
$176.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$145.61
|
| Rate for Payer: Priority Health SBD |
$131.05
|
|
|
HC HOME SLEEP TEST/TYPE 4 PORTA
|
Facility
|
IP
|
$208.01
|
|
|
Service Code
|
HCPCS G0400
|
| Hospital Charge Code |
92000028
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$131.05 |
| Max. Negotiated Rate |
$187.21 |
| Rate for Payer: Aetna Commercial |
$176.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$135.21
|
| Rate for Payer: Cash Price |
$166.41
|
| Rate for Payer: Cofinity Commercial |
$178.89
|
| Rate for Payer: Cofinity Commercial |
$145.61
|
| Rate for Payer: Healthscope Commercial |
$187.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$176.81
|
| Rate for Payer: PHP Commercial |
$176.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$145.61
|
| Rate for Payer: Priority Health SBD |
$131.05
|
|
|
HC HOME SLEEP TEST/TYPE 4 PORTA
|
Facility
|
OP
|
$208.01
|
|
|
Service Code
|
HCPCS G0400
|
| Hospital Charge Code |
92000028
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$131.05 |
| Max. Negotiated Rate |
$824.04 |
| Rate for Payer: Aetna Commercial |
$176.81
|
| Rate for Payer: Aetna Medicare |
$290.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$135.21
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$349.11
|
| Rate for Payer: Amish Plain Church Group Commercial |
$349.11
|
| Rate for Payer: BCBS Complete |
$160.42
|
| Rate for Payer: BCBS MAPPO |
$279.29
|
| Rate for Payer: BCN Medicare Advantage |
$279.29
|
| Rate for Payer: Cash Price |
$166.41
|
| Rate for Payer: Cash Price |
$166.41
|
| Rate for Payer: Cofinity Commercial |
$145.61
|
| Rate for Payer: Cofinity Commercial |
$178.89
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$279.29
|
| Rate for Payer: Healthscope Commercial |
$187.21
|
| Rate for Payer: Mclaren Medicaid |
$152.77
|
| Rate for Payer: Mclaren Medicare |
$279.29
|
| Rate for Payer: Meridian Medicaid |
$160.42
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$293.25
|
| Rate for Payer: MI Amish Medical Board Commercial |
$321.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$176.81
|
| Rate for Payer: PACE Medicare |
$265.33
|
| Rate for Payer: PACE SWMI |
$279.29
|
| Rate for Payer: PHP Commercial |
$176.81
|
| Rate for Payer: PHP Medicare Advantage |
$279.29
|
| Rate for Payer: Priority Health Choice Medicaid |
$152.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$145.61
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$824.04
|
| Rate for Payer: Priority Health Medicare |
$279.29
|
| Rate for Payer: Priority Health Narrow Network |
$659.23
|
| Rate for Payer: Priority Health SBD |
$131.05
|
| Rate for Payer: Railroad Medicare Medicare |
$279.29
|
| Rate for Payer: UHC Dual Complete DSNP |
$279.29
|
| Rate for Payer: UHC Medicare Advantage |
$287.67
|
| Rate for Payer: VA VA |
$279.29
|
|
|
HC HOMOCYSTEINE SERUM
|
Facility
|
OP
|
$51.00
|
|
|
Service Code
|
CPT 83090
|
| Hospital Charge Code |
30100243
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$9.80 |
| Max. Negotiated Rate |
$45.90 |
| Rate for Payer: Aetna Commercial |
$43.35
|
| Rate for Payer: Aetna Medicare |
$18.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$33.15
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$22.40
|
| Rate for Payer: Amish Plain Church Group Commercial |
$22.40
|
| Rate for Payer: BCBS Complete |
$10.29
|
| Rate for Payer: BCBS MAPPO |
$17.92
|
| Rate for Payer: BCBS Trust/PPO |
$14.03
|
| Rate for Payer: BCN Medicare Advantage |
$17.92
|
| Rate for Payer: Cash Price |
$40.80
|
| Rate for Payer: Cash Price |
$40.80
|
| Rate for Payer: Cofinity Commercial |
$35.70
|
| Rate for Payer: Cofinity Commercial |
$43.86
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$17.92
|
| Rate for Payer: Healthscope Commercial |
$45.90
|
| Rate for Payer: Mclaren Medicaid |
$9.80
|
| Rate for Payer: Mclaren Medicare |
$17.92
|
| Rate for Payer: Meridian Medicaid |
$10.29
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$18.82
|
| Rate for Payer: MI Amish Medical Board Commercial |
$20.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$43.35
|
| Rate for Payer: PACE Medicare |
$17.02
|
| Rate for Payer: PACE SWMI |
$17.92
|
| Rate for Payer: PHP Commercial |
$43.35
|
| Rate for Payer: PHP Medicare Advantage |
$17.92
|
| Rate for Payer: Priority Health Choice Medicaid |
$9.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$35.70
|
| Rate for Payer: Priority Health Medicare |
$17.92
|
| Rate for Payer: Priority Health SBD |
$32.13
|
| Rate for Payer: Railroad Medicare Medicare |
$17.92
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$21.50
|
| Rate for Payer: UHC Core |
$28.67
|
| Rate for Payer: UHC Dual Complete DSNP |
$17.92
|
| Rate for Payer: UHC Exchange |
$17.92
|
| Rate for Payer: UHC Medicare Advantage |
$18.46
|
| Rate for Payer: VA VA |
$17.92
|
|
|
HC HOMOCYSTEINE SERUM
|
Facility
|
IP
|
$51.00
|
|
|
Service Code
|
CPT 83090
|
| Hospital Charge Code |
30100243
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$32.13 |
| Max. Negotiated Rate |
$45.90 |
| Rate for Payer: Aetna Commercial |
$43.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$33.15
|
| Rate for Payer: Cash Price |
$40.80
|
| Rate for Payer: Cofinity Commercial |
$35.70
|
| Rate for Payer: Cofinity Commercial |
$43.86
|
| Rate for Payer: Healthscope Commercial |
$45.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$43.35
|
| Rate for Payer: PHP Commercial |
$43.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$35.70
|
| Rate for Payer: Priority Health SBD |
$32.13
|
|
|
HC HOMOVANILLIC ACID RANDOM URINE
|
Facility
|
IP
|
$62.22
|
|
|
Service Code
|
CPT 83150
|
| Hospital Charge Code |
30100474
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$39.20 |
| Max. Negotiated Rate |
$56.00 |
| Rate for Payer: Aetna Commercial |
$52.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$40.44
|
| Rate for Payer: Cash Price |
$49.78
|
| Rate for Payer: Cofinity Commercial |
$43.55
|
| Rate for Payer: Cofinity Commercial |
$53.51
|
| Rate for Payer: Healthscope Commercial |
$56.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$52.89
|
| Rate for Payer: PHP Commercial |
$52.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$43.55
|
| Rate for Payer: Priority Health SBD |
$39.20
|
|
|
HC HOMOVANILLIC ACID RANDOM URINE
|
Facility
|
OP
|
$62.22
|
|
|
Service Code
|
CPT 83150
|
| Hospital Charge Code |
30100474
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$12.26 |
| Max. Negotiated Rate |
$56.00 |
| Rate for Payer: Aetna Commercial |
$52.89
|
| Rate for Payer: Aetna Medicare |
$23.31
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$40.44
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$28.01
|
| Rate for Payer: Amish Plain Church Group Commercial |
$28.01
|
| Rate for Payer: BCBS Complete |
$12.87
|
| Rate for Payer: BCBS MAPPO |
$22.41
|
| Rate for Payer: BCBS Trust/PPO |
$17.55
|
| Rate for Payer: BCN Medicare Advantage |
$22.41
|
| Rate for Payer: Cash Price |
$49.78
|
| Rate for Payer: Cash Price |
$49.78
|
| Rate for Payer: Cofinity Commercial |
$43.55
|
| Rate for Payer: Cofinity Commercial |
$53.51
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$22.41
|
| Rate for Payer: Healthscope Commercial |
$56.00
|
| Rate for Payer: Mclaren Medicaid |
$12.26
|
| Rate for Payer: Mclaren Medicare |
$22.41
|
| Rate for Payer: Meridian Medicaid |
$12.87
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$23.53
|
| Rate for Payer: MI Amish Medical Board Commercial |
$25.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$52.89
|
| Rate for Payer: PACE Medicare |
$21.29
|
| Rate for Payer: PACE SWMI |
$22.41
|
| Rate for Payer: PHP Commercial |
$52.89
|
| Rate for Payer: PHP Medicare Advantage |
$22.41
|
| Rate for Payer: Priority Health Choice Medicaid |
$12.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$43.55
|
| Rate for Payer: Priority Health Medicare |
$22.41
|
| Rate for Payer: Priority Health SBD |
$39.20
|
| Rate for Payer: Railroad Medicare Medicare |
$22.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$26.89
|
| Rate for Payer: UHC Core |
$32.88
|
| Rate for Payer: UHC Dual Complete DSNP |
$22.41
|
| Rate for Payer: UHC Exchange |
$22.41
|
| Rate for Payer: UHC Medicare Advantage |
$23.08
|
| Rate for Payer: VA VA |
$22.41
|
|
|
HC HOMOVANILLIC ACID URINE
|
Facility
|
OP
|
$62.22
|
|
|
Service Code
|
CPT 83150
|
| Hospital Charge Code |
30100244
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$12.26 |
| Max. Negotiated Rate |
$56.00 |
| Rate for Payer: Aetna Commercial |
$52.89
|
| Rate for Payer: Aetna Medicare |
$23.31
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$40.44
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$28.01
|
| Rate for Payer: Amish Plain Church Group Commercial |
$28.01
|
| Rate for Payer: BCBS Complete |
$12.87
|
| Rate for Payer: BCBS MAPPO |
$22.41
|
| Rate for Payer: BCBS Trust/PPO |
$17.55
|
| Rate for Payer: BCN Medicare Advantage |
$22.41
|
| Rate for Payer: Cash Price |
$49.78
|
| Rate for Payer: Cash Price |
$49.78
|
| Rate for Payer: Cofinity Commercial |
$53.51
|
| Rate for Payer: Cofinity Commercial |
$43.55
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$22.41
|
| Rate for Payer: Healthscope Commercial |
$56.00
|
| Rate for Payer: Mclaren Medicaid |
$12.26
|
| Rate for Payer: Mclaren Medicare |
$22.41
|
| Rate for Payer: Meridian Medicaid |
$12.87
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$23.53
|
| Rate for Payer: MI Amish Medical Board Commercial |
$25.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$52.89
|
| Rate for Payer: PACE Medicare |
$21.29
|
| Rate for Payer: PACE SWMI |
$22.41
|
| Rate for Payer: PHP Commercial |
$52.89
|
| Rate for Payer: PHP Medicare Advantage |
$22.41
|
| Rate for Payer: Priority Health Choice Medicaid |
$12.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$43.55
|
| Rate for Payer: Priority Health Medicare |
$22.41
|
| Rate for Payer: Priority Health SBD |
$39.20
|
| Rate for Payer: Railroad Medicare Medicare |
$22.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$26.89
|
| Rate for Payer: UHC Core |
$32.88
|
| Rate for Payer: UHC Dual Complete DSNP |
$22.41
|
| Rate for Payer: UHC Exchange |
$22.41
|
| Rate for Payer: UHC Medicare Advantage |
$23.08
|
| Rate for Payer: VA VA |
$22.41
|
|
|
HC HOMOVANILLIC ACID URINE
|
Facility
|
IP
|
$62.22
|
|
|
Service Code
|
CPT 83150
|
| Hospital Charge Code |
30100244
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$39.20 |
| Max. Negotiated Rate |
$56.00 |
| Rate for Payer: Aetna Commercial |
$52.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$40.44
|
| Rate for Payer: Cash Price |
$49.78
|
| Rate for Payer: Cofinity Commercial |
$43.55
|
| Rate for Payer: Cofinity Commercial |
$53.51
|
| Rate for Payer: Healthscope Commercial |
$56.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$52.89
|
| Rate for Payer: PHP Commercial |
$52.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$43.55
|
| Rate for Payer: Priority Health SBD |
$39.20
|
|
|
HC HONEY BEE IGE
|
Facility
|
OP
|
$24.89
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
30200089
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$2.86 |
| Max. Negotiated Rate |
$22.40 |
| Rate for Payer: Aetna Commercial |
$21.16
|
| Rate for Payer: Aetna Medicare |
$5.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.18
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6.52
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6.52
|
| Rate for Payer: BCBS Complete |
$3.00
|
| Rate for Payer: BCBS MAPPO |
$5.22
|
| Rate for Payer: BCBS Trust/PPO |
$4.09
|
| Rate for Payer: BCN Medicare Advantage |
$5.22
|
| Rate for Payer: Cash Price |
$19.91
|
| Rate for Payer: Cash Price |
$19.91
|
| Rate for Payer: Cofinity Commercial |
$17.42
|
| Rate for Payer: Cofinity Commercial |
$21.41
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5.22
|
| Rate for Payer: Healthscope Commercial |
$22.40
|
| Rate for Payer: Mclaren Medicaid |
$2.86
|
| Rate for Payer: Mclaren Medicare |
$5.22
|
| Rate for Payer: Meridian Medicaid |
$3.00
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$5.48
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.16
|
| Rate for Payer: PACE Medicare |
$4.96
|
| Rate for Payer: PACE SWMI |
$5.22
|
| Rate for Payer: PHP Commercial |
$21.16
|
| Rate for Payer: PHP Medicare Advantage |
$5.22
|
| Rate for Payer: Priority Health Choice Medicaid |
$2.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.42
|
| Rate for Payer: Priority Health Medicare |
$5.22
|
| Rate for Payer: Priority Health SBD |
$15.68
|
| Rate for Payer: Railroad Medicare Medicare |
$5.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$6.26
|
| Rate for Payer: UHC Core |
$8.87
|
| Rate for Payer: UHC Dual Complete DSNP |
$5.22
|
| Rate for Payer: UHC Exchange |
$5.22
|
| Rate for Payer: UHC Medicare Advantage |
$5.38
|
| Rate for Payer: VA VA |
$5.22
|
|
|
HC HONEY BEE IGE
|
Facility
|
IP
|
$24.89
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
30200089
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$15.68 |
| Max. Negotiated Rate |
$22.40 |
| Rate for Payer: Aetna Commercial |
$21.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.18
|
| Rate for Payer: Cash Price |
$19.91
|
| Rate for Payer: Cofinity Commercial |
$21.41
|
| Rate for Payer: Cofinity Commercial |
$17.42
|
| Rate for Payer: Healthscope Commercial |
$22.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.16
|
| Rate for Payer: PHP Commercial |
$21.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.42
|
| Rate for Payer: Priority Health SBD |
$15.68
|
|
|
HC HOSP OUTPT CONSULT LVL 2
|
Facility
|
OP
|
$276.00
|
|
|
Service Code
|
HCPCS G0463
|
| Hospital Charge Code |
51000125
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$64.34 |
| Max. Negotiated Rate |
$369.96 |
| Rate for Payer: Aetna Commercial |
$234.60
|
| Rate for Payer: Aetna Medicare |
$122.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$179.40
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$147.02
|
| Rate for Payer: Amish Plain Church Group Commercial |
$147.02
|
| Rate for Payer: BCBS Complete |
$67.56
|
| Rate for Payer: BCBS MAPPO |
$117.62
|
| Rate for Payer: BCBS Trust/PPO |
$351.18
|
| Rate for Payer: BCN Medicare Advantage |
$117.62
|
| Rate for Payer: Cash Price |
$220.80
|
| Rate for Payer: Cash Price |
$220.80
|
| Rate for Payer: Cofinity Commercial |
$237.36
|
| Rate for Payer: Cofinity Commercial |
$193.20
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$117.62
|
| Rate for Payer: Healthscope Commercial |
$248.40
|
| Rate for Payer: Mclaren Medicaid |
$64.34
|
| Rate for Payer: Mclaren Medicare |
$117.62
|
| Rate for Payer: Meridian Medicaid |
$67.56
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$123.50
|
| Rate for Payer: MI Amish Medical Board Commercial |
$135.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$234.60
|
| Rate for Payer: PACE Medicare |
$111.74
|
| Rate for Payer: PACE SWMI |
$117.62
|
| Rate for Payer: PHP Commercial |
$234.60
|
| Rate for Payer: PHP Medicare Advantage |
$117.62
|
| Rate for Payer: Priority Health Choice Medicaid |
$64.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$193.20
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$369.96
|
| Rate for Payer: Priority Health Medicare |
$117.62
|
| Rate for Payer: Priority Health Narrow Network |
$295.97
|
| Rate for Payer: Priority Health SBD |
$173.88
|
| Rate for Payer: Railroad Medicare Medicare |
$117.62
|
| Rate for Payer: UHC Dual Complete DSNP |
$117.62
|
| Rate for Payer: UHC Medicare Advantage |
$121.15
|
| Rate for Payer: VA VA |
$117.62
|
|
|
HC HOSP OUTPT CONSULT LVL 2
|
Facility
|
IP
|
$276.00
|
|
|
Service Code
|
HCPCS G0463
|
| Hospital Charge Code |
51000125
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$173.88 |
| Max. Negotiated Rate |
$248.40 |
| Rate for Payer: Aetna Commercial |
$234.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$179.40
|
| Rate for Payer: Cash Price |
$220.80
|
| Rate for Payer: Cofinity Commercial |
$193.20
|
| Rate for Payer: Cofinity Commercial |
$237.36
|
| Rate for Payer: Healthscope Commercial |
$248.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$234.60
|
| Rate for Payer: PHP Commercial |
$234.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$193.20
|
| Rate for Payer: Priority Health SBD |
$173.88
|
|
|
HC HOSP OUTPT CONSULT LVL 3
|
Facility
|
IP
|
$276.00
|
|
|
Service Code
|
HCPCS G0463
|
| Hospital Charge Code |
51000126
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$173.88 |
| Max. Negotiated Rate |
$248.40 |
| Rate for Payer: Aetna Commercial |
$234.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$179.40
|
| Rate for Payer: Cash Price |
$220.80
|
| Rate for Payer: Cofinity Commercial |
$193.20
|
| Rate for Payer: Cofinity Commercial |
$237.36
|
| Rate for Payer: Healthscope Commercial |
$248.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$234.60
|
| Rate for Payer: PHP Commercial |
$234.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$193.20
|
| Rate for Payer: Priority Health SBD |
$173.88
|
|
|
HC HOSP OUTPT CONSULT LVL 3
|
Facility
|
OP
|
$276.00
|
|
|
Service Code
|
HCPCS G0463
|
| Hospital Charge Code |
51000126
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$64.34 |
| Max. Negotiated Rate |
$369.96 |
| Rate for Payer: Aetna Commercial |
$234.60
|
| Rate for Payer: Aetna Medicare |
$122.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$179.40
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$147.02
|
| Rate for Payer: Amish Plain Church Group Commercial |
$147.02
|
| Rate for Payer: BCBS Complete |
$67.56
|
| Rate for Payer: BCBS MAPPO |
$117.62
|
| Rate for Payer: BCBS Trust/PPO |
$351.18
|
| Rate for Payer: BCN Medicare Advantage |
$117.62
|
| Rate for Payer: Cash Price |
$220.80
|
| Rate for Payer: Cash Price |
$220.80
|
| Rate for Payer: Cofinity Commercial |
$237.36
|
| Rate for Payer: Cofinity Commercial |
$193.20
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$117.62
|
| Rate for Payer: Healthscope Commercial |
$248.40
|
| Rate for Payer: Mclaren Medicaid |
$64.34
|
| Rate for Payer: Mclaren Medicare |
$117.62
|
| Rate for Payer: Meridian Medicaid |
$67.56
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$123.50
|
| Rate for Payer: MI Amish Medical Board Commercial |
$135.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$234.60
|
| Rate for Payer: PACE Medicare |
$111.74
|
| Rate for Payer: PACE SWMI |
$117.62
|
| Rate for Payer: PHP Commercial |
$234.60
|
| Rate for Payer: PHP Medicare Advantage |
$117.62
|
| Rate for Payer: Priority Health Choice Medicaid |
$64.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$193.20
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$369.96
|
| Rate for Payer: Priority Health Medicare |
$117.62
|
| Rate for Payer: Priority Health Narrow Network |
$295.97
|
| Rate for Payer: Priority Health SBD |
$173.88
|
| Rate for Payer: Railroad Medicare Medicare |
$117.62
|
| Rate for Payer: UHC Dual Complete DSNP |
$117.62
|
| Rate for Payer: UHC Medicare Advantage |
$121.15
|
| Rate for Payer: VA VA |
$117.62
|
|
|
HC HOSP OUTPT CONSULT LVL 4
|
Facility
|
IP
|
$276.00
|
|
|
Service Code
|
HCPCS G0463
|
| Hospital Charge Code |
51000127
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$173.88 |
| Max. Negotiated Rate |
$248.40 |
| Rate for Payer: Aetna Commercial |
$234.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$179.40
|
| Rate for Payer: Cash Price |
$220.80
|
| Rate for Payer: Cofinity Commercial |
$193.20
|
| Rate for Payer: Cofinity Commercial |
$237.36
|
| Rate for Payer: Healthscope Commercial |
$248.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$234.60
|
| Rate for Payer: PHP Commercial |
$234.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$193.20
|
| Rate for Payer: Priority Health SBD |
$173.88
|
|
|
HC HOSP OUTPT CONSULT LVL 4
|
Facility
|
OP
|
$276.00
|
|
|
Service Code
|
HCPCS G0463
|
| Hospital Charge Code |
51000127
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$64.34 |
| Max. Negotiated Rate |
$369.96 |
| Rate for Payer: Aetna Commercial |
$234.60
|
| Rate for Payer: Aetna Medicare |
$122.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$179.40
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$147.02
|
| Rate for Payer: Amish Plain Church Group Commercial |
$147.02
|
| Rate for Payer: BCBS Complete |
$67.56
|
| Rate for Payer: BCBS MAPPO |
$117.62
|
| Rate for Payer: BCBS Trust/PPO |
$351.18
|
| Rate for Payer: BCN Medicare Advantage |
$117.62
|
| Rate for Payer: Cash Price |
$220.80
|
| Rate for Payer: Cash Price |
$220.80
|
| Rate for Payer: Cofinity Commercial |
$193.20
|
| Rate for Payer: Cofinity Commercial |
$237.36
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$117.62
|
| Rate for Payer: Healthscope Commercial |
$248.40
|
| Rate for Payer: Mclaren Medicaid |
$64.34
|
| Rate for Payer: Mclaren Medicare |
$117.62
|
| Rate for Payer: Meridian Medicaid |
$67.56
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$123.50
|
| Rate for Payer: MI Amish Medical Board Commercial |
$135.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$234.60
|
| Rate for Payer: PACE Medicare |
$111.74
|
| Rate for Payer: PACE SWMI |
$117.62
|
| Rate for Payer: PHP Commercial |
$234.60
|
| Rate for Payer: PHP Medicare Advantage |
$117.62
|
| Rate for Payer: Priority Health Choice Medicaid |
$64.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$193.20
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$369.96
|
| Rate for Payer: Priority Health Medicare |
$117.62
|
| Rate for Payer: Priority Health Narrow Network |
$295.97
|
| Rate for Payer: Priority Health SBD |
$173.88
|
| Rate for Payer: Railroad Medicare Medicare |
$117.62
|
| Rate for Payer: UHC Dual Complete DSNP |
$117.62
|
| Rate for Payer: UHC Medicare Advantage |
$121.15
|
| Rate for Payer: VA VA |
$117.62
|
|
|
HC HOSP OUTPT CONSULT LVL 5
|
Facility
|
IP
|
$276.00
|
|
|
Service Code
|
HCPCS G0463
|
| Hospital Charge Code |
51000128
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$173.88 |
| Max. Negotiated Rate |
$248.40 |
| Rate for Payer: Aetna Commercial |
$234.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$179.40
|
| Rate for Payer: Cash Price |
$220.80
|
| Rate for Payer: Cofinity Commercial |
$193.20
|
| Rate for Payer: Cofinity Commercial |
$237.36
|
| Rate for Payer: Healthscope Commercial |
$248.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$234.60
|
| Rate for Payer: PHP Commercial |
$234.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$193.20
|
| Rate for Payer: Priority Health SBD |
$173.88
|
|
|
HC HOSP OUTPT CONSULT LVL 5
|
Facility
|
OP
|
$276.00
|
|
|
Service Code
|
HCPCS G0463
|
| Hospital Charge Code |
51000128
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$64.34 |
| Max. Negotiated Rate |
$369.96 |
| Rate for Payer: Aetna Commercial |
$234.60
|
| Rate for Payer: Aetna Medicare |
$122.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$179.40
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$147.02
|
| Rate for Payer: Amish Plain Church Group Commercial |
$147.02
|
| Rate for Payer: BCBS Complete |
$67.56
|
| Rate for Payer: BCBS MAPPO |
$117.62
|
| Rate for Payer: BCBS Trust/PPO |
$351.18
|
| Rate for Payer: BCN Medicare Advantage |
$117.62
|
| Rate for Payer: Cash Price |
$220.80
|
| Rate for Payer: Cash Price |
$220.80
|
| Rate for Payer: Cofinity Commercial |
$193.20
|
| Rate for Payer: Cofinity Commercial |
$237.36
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$117.62
|
| Rate for Payer: Healthscope Commercial |
$248.40
|
| Rate for Payer: Mclaren Medicaid |
$64.34
|
| Rate for Payer: Mclaren Medicare |
$117.62
|
| Rate for Payer: Meridian Medicaid |
$67.56
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$123.50
|
| Rate for Payer: MI Amish Medical Board Commercial |
$135.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$234.60
|
| Rate for Payer: PACE Medicare |
$111.74
|
| Rate for Payer: PACE SWMI |
$117.62
|
| Rate for Payer: PHP Commercial |
$234.60
|
| Rate for Payer: PHP Medicare Advantage |
$117.62
|
| Rate for Payer: Priority Health Choice Medicaid |
$64.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$193.20
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$369.96
|
| Rate for Payer: Priority Health Medicare |
$117.62
|
| Rate for Payer: Priority Health Narrow Network |
$295.97
|
| Rate for Payer: Priority Health SBD |
$173.88
|
| Rate for Payer: Railroad Medicare Medicare |
$117.62
|
| Rate for Payer: UHC Dual Complete DSNP |
$117.62
|
| Rate for Payer: UHC Medicare Advantage |
$121.15
|
| Rate for Payer: VA VA |
$117.62
|
|
|
HC HOSP OUTPT VISIT EST LVL 1
|
Facility
|
OP
|
$276.00
|
|
|
Service Code
|
HCPCS G0463
|
| Hospital Charge Code |
51000116
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$64.34 |
| Max. Negotiated Rate |
$369.96 |
| Rate for Payer: Aetna Commercial |
$234.60
|
| Rate for Payer: Aetna Medicare |
$122.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$179.40
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$147.02
|
| Rate for Payer: Amish Plain Church Group Commercial |
$147.02
|
| Rate for Payer: BCBS Complete |
$67.56
|
| Rate for Payer: BCBS MAPPO |
$117.62
|
| Rate for Payer: BCBS Trust/PPO |
$351.18
|
| Rate for Payer: BCN Medicare Advantage |
$117.62
|
| Rate for Payer: Cash Price |
$220.80
|
| Rate for Payer: Cash Price |
$220.80
|
| Rate for Payer: Cofinity Commercial |
$237.36
|
| Rate for Payer: Cofinity Commercial |
$193.20
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$117.62
|
| Rate for Payer: Healthscope Commercial |
$248.40
|
| Rate for Payer: Mclaren Medicaid |
$64.34
|
| Rate for Payer: Mclaren Medicare |
$117.62
|
| Rate for Payer: Meridian Medicaid |
$67.56
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$123.50
|
| Rate for Payer: MI Amish Medical Board Commercial |
$135.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$234.60
|
| Rate for Payer: PACE Medicare |
$111.74
|
| Rate for Payer: PACE SWMI |
$117.62
|
| Rate for Payer: PHP Commercial |
$234.60
|
| Rate for Payer: PHP Medicare Advantage |
$117.62
|
| Rate for Payer: Priority Health Choice Medicaid |
$64.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$193.20
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$369.96
|
| Rate for Payer: Priority Health Medicare |
$117.62
|
| Rate for Payer: Priority Health Narrow Network |
$295.97
|
| Rate for Payer: Priority Health SBD |
$173.88
|
| Rate for Payer: Railroad Medicare Medicare |
$117.62
|
| Rate for Payer: UHC Dual Complete DSNP |
$117.62
|
| Rate for Payer: UHC Medicare Advantage |
$121.15
|
| Rate for Payer: VA VA |
$117.62
|
|
|
HC HOSP OUTPT VISIT EST LVL 1
|
Facility
|
IP
|
$276.00
|
|
|
Service Code
|
HCPCS G0463
|
| Hospital Charge Code |
51000116
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$173.88 |
| Max. Negotiated Rate |
$248.40 |
| Rate for Payer: Aetna Commercial |
$234.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$179.40
|
| Rate for Payer: Cash Price |
$220.80
|
| Rate for Payer: Cofinity Commercial |
$193.20
|
| Rate for Payer: Cofinity Commercial |
$237.36
|
| Rate for Payer: Healthscope Commercial |
$248.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$234.60
|
| Rate for Payer: PHP Commercial |
$234.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$193.20
|
| Rate for Payer: Priority Health SBD |
$173.88
|
|
|
HC HOSP OUTPT VISIT EST LVL 2
|
Facility
|
OP
|
$276.00
|
|
|
Service Code
|
HCPCS G0463
|
| Hospital Charge Code |
51000117
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$64.34 |
| Max. Negotiated Rate |
$369.96 |
| Rate for Payer: Aetna Commercial |
$234.60
|
| Rate for Payer: Aetna Medicare |
$122.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$179.40
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$147.02
|
| Rate for Payer: Amish Plain Church Group Commercial |
$147.02
|
| Rate for Payer: BCBS Complete |
$67.56
|
| Rate for Payer: BCBS MAPPO |
$117.62
|
| Rate for Payer: BCBS Trust/PPO |
$351.18
|
| Rate for Payer: BCN Medicare Advantage |
$117.62
|
| Rate for Payer: Cash Price |
$220.80
|
| Rate for Payer: Cash Price |
$220.80
|
| Rate for Payer: Cofinity Commercial |
$237.36
|
| Rate for Payer: Cofinity Commercial |
$193.20
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$117.62
|
| Rate for Payer: Healthscope Commercial |
$248.40
|
| Rate for Payer: Mclaren Medicaid |
$64.34
|
| Rate for Payer: Mclaren Medicare |
$117.62
|
| Rate for Payer: Meridian Medicaid |
$67.56
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$123.50
|
| Rate for Payer: MI Amish Medical Board Commercial |
$135.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$234.60
|
| Rate for Payer: PACE Medicare |
$111.74
|
| Rate for Payer: PACE SWMI |
$117.62
|
| Rate for Payer: PHP Commercial |
$234.60
|
| Rate for Payer: PHP Medicare Advantage |
$117.62
|
| Rate for Payer: Priority Health Choice Medicaid |
$64.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$193.20
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$369.96
|
| Rate for Payer: Priority Health Medicare |
$117.62
|
| Rate for Payer: Priority Health Narrow Network |
$295.97
|
| Rate for Payer: Priority Health SBD |
$173.88
|
| Rate for Payer: Railroad Medicare Medicare |
$117.62
|
| Rate for Payer: UHC Dual Complete DSNP |
$117.62
|
| Rate for Payer: UHC Medicare Advantage |
$121.15
|
| Rate for Payer: VA VA |
$117.62
|
|
|
HC HOSP OUTPT VISIT EST LVL 2
|
Facility
|
IP
|
$276.00
|
|
|
Service Code
|
HCPCS G0463
|
| Hospital Charge Code |
51000117
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$173.88 |
| Max. Negotiated Rate |
$248.40 |
| Rate for Payer: Aetna Commercial |
$234.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$179.40
|
| Rate for Payer: Cash Price |
$220.80
|
| Rate for Payer: Cofinity Commercial |
$193.20
|
| Rate for Payer: Cofinity Commercial |
$237.36
|
| Rate for Payer: Healthscope Commercial |
$248.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$234.60
|
| Rate for Payer: PHP Commercial |
$234.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$193.20
|
| Rate for Payer: Priority Health SBD |
$173.88
|
|
