|
HC NM SENTINEL NODE INJ NON-IMAGI
|
Facility
|
IP
|
$991.36
|
|
|
Service Code
|
CPT 38792
|
| Hospital Charge Code |
36100187
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$624.56 |
| Max. Negotiated Rate |
$892.22 |
| Rate for Payer: Aetna Commercial |
$842.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$644.38
|
| Rate for Payer: Cash Price |
$793.09
|
| Rate for Payer: Cofinity Commercial |
$693.95
|
| Rate for Payer: Cofinity Commercial |
$852.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$693.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$793.09
|
| Rate for Payer: Healthscope Commercial |
$892.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$842.66
|
| Rate for Payer: PHP Commercial |
$842.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$644.38
|
| Rate for Payer: Priority Health SBD |
$624.56
|
|
|
HC NM TC 99M TILMANOCEPT DX PER 0.5 MCI
|
Facility
|
IP
|
$1,106.96
|
|
|
Service Code
|
HCPCS A9520
|
| Hospital Charge Code |
34300033
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$697.38 |
| Max. Negotiated Rate |
$996.26 |
| Rate for Payer: Aetna Commercial |
$940.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$719.52
|
| Rate for Payer: Cash Price |
$885.57
|
| Rate for Payer: Cofinity Commercial |
$774.87
|
| Rate for Payer: Cofinity Commercial |
$951.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$774.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$885.57
|
| Rate for Payer: Healthscope Commercial |
$996.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$940.92
|
| Rate for Payer: PHP Commercial |
$940.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$719.52
|
| Rate for Payer: Priority Health SBD |
$697.38
|
|
|
HC NM TC 99M TILMANOCEPT DX PER 0.5 MCI
|
Facility
|
OP
|
$1,106.96
|
|
|
Service Code
|
HCPCS A9520
|
| Hospital Charge Code |
34300033
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$442.78 |
| Max. Negotiated Rate |
$996.26 |
| Rate for Payer: Aetna Commercial |
$940.92
|
| Rate for Payer: Aetna Medicare |
$553.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$719.52
|
| Rate for Payer: BCBS Complete |
$442.78
|
| Rate for Payer: Cash Price |
$885.57
|
| Rate for Payer: Cofinity Commercial |
$774.87
|
| Rate for Payer: Cofinity Commercial |
$951.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$774.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$885.57
|
| Rate for Payer: Healthscope Commercial |
$996.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$940.92
|
| Rate for Payer: PHP Commercial |
$940.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$719.52
|
| Rate for Payer: Priority Health SBD |
$697.38
|
|
|
HC NM THYROID CA METS IMGI131 TOTAL
|
Facility
|
OP
|
$1,263.44
|
|
|
Service Code
|
CPT 78018
|
| Hospital Charge Code |
34100006
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$281.38 |
| Max. Negotiated Rate |
$1,477.71 |
| Rate for Payer: Aetna Commercial |
$1,073.92
|
| Rate for Payer: Aetna Medicare |
$545.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$821.24
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$656.20
|
| Rate for Payer: Amish Plain Church Group Commercial |
$656.20
|
| Rate for Payer: BCBS Complete |
$295.45
|
| Rate for Payer: BCBS MAPPO |
$524.96
|
| Rate for Payer: BCN Medicare Advantage |
$524.96
|
| Rate for Payer: Cash Price |
$1,010.75
|
| Rate for Payer: Cash Price |
$1,010.75
|
| Rate for Payer: Cofinity Commercial |
$1,086.56
|
| Rate for Payer: Cofinity Commercial |
$884.41
|
| Rate for Payer: Cofinity Medicare Advantage |
$884.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,010.75
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$524.96
|
| Rate for Payer: Healthscope Commercial |
$1,137.10
|
| Rate for Payer: Mclaren Medicaid |
$281.38
|
| Rate for Payer: Mclaren Medicare |
$524.96
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$551.21
|
| Rate for Payer: Meridian Medicaid |
$295.45
|
| Rate for Payer: MI Amish Medical Board Commercial |
$603.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,073.92
|
| Rate for Payer: PACE Medicare |
$498.71
|
| Rate for Payer: PACE SWMI |
$524.96
|
| Rate for Payer: PHP Commercial |
$1,073.92
|
| Rate for Payer: PHP Medicare Advantage |
$524.96
|
| Rate for Payer: Priority Health Choice Medicaid |
$281.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$821.24
|
| Rate for Payer: Priority Health Medicare |
$524.96
|
| Rate for Payer: Priority Health SBD |
$795.97
|
| Rate for Payer: Railroad Medicare Medicare |
$524.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,477.71
|
| Rate for Payer: UHC Core |
$934.95
|
| Rate for Payer: UHC Dual Complete DSNP |
$524.96
|
| Rate for Payer: UHC Exchange |
$934.95
|
| Rate for Payer: UHC Medicare Advantage |
$524.96
|
| Rate for Payer: UHCCP Medicaid |
$295.55
|
| Rate for Payer: VA VA |
$524.96
|
|
|
HC NM THYROID CA METS IMGI131 TOTAL
|
Facility
|
IP
|
$1,263.44
|
|
|
Service Code
|
CPT 78018
|
| Hospital Charge Code |
34100006
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$795.97 |
| Max. Negotiated Rate |
$1,137.10 |
| Rate for Payer: Aetna Commercial |
$1,073.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$821.24
|
| Rate for Payer: Cash Price |
$1,010.75
|
| Rate for Payer: Cofinity Commercial |
$1,086.56
|
| Rate for Payer: Cofinity Commercial |
$884.41
|
| Rate for Payer: Cofinity Medicare Advantage |
$884.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,010.75
|
| Rate for Payer: Healthscope Commercial |
$1,137.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,073.92
|
| Rate for Payer: PHP Commercial |
$1,073.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$821.24
|
| Rate for Payer: Priority Health SBD |
$795.97
|
|
|
HC NM TUMOR LOCALIZATION SPECT 2 AREAS
|
Facility
|
OP
|
$1,985.39
|
|
|
Service Code
|
CPT 78831
|
| Hospital Charge Code |
34100081
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$682.44 |
| Max. Negotiated Rate |
$3,583.96 |
| Rate for Payer: Aetna Commercial |
$1,687.58
|
| Rate for Payer: Aetna Medicare |
$1,324.14
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,290.50
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1,591.51
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1,591.51
|
| Rate for Payer: BCBS Complete |
$716.56
|
| Rate for Payer: BCBS MAPPO |
$1,273.21
|
| Rate for Payer: BCN Medicare Advantage |
$1,273.21
|
| Rate for Payer: Cash Price |
$1,588.31
|
| Rate for Payer: Cash Price |
$1,588.31
|
| Rate for Payer: Cofinity Commercial |
$1,707.44
|
| Rate for Payer: Cofinity Commercial |
$1,389.77
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,389.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,588.31
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,273.21
|
| Rate for Payer: Healthscope Commercial |
$1,786.85
|
| Rate for Payer: Mclaren Medicaid |
$682.44
|
| Rate for Payer: Mclaren Medicare |
$1,273.21
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,336.87
|
| Rate for Payer: Meridian Medicaid |
$716.56
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,464.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,687.58
|
| Rate for Payer: PACE Medicare |
$1,209.55
|
| Rate for Payer: PACE SWMI |
$1,273.21
|
| Rate for Payer: PHP Commercial |
$1,687.58
|
| Rate for Payer: PHP Medicare Advantage |
$1,273.21
|
| Rate for Payer: Priority Health Choice Medicaid |
$682.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,290.50
|
| Rate for Payer: Priority Health Medicare |
$1,273.21
|
| Rate for Payer: Priority Health SBD |
$1,250.80
|
| Rate for Payer: Railroad Medicare Medicare |
$1,273.21
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3,583.96
|
| Rate for Payer: UHC Core |
$1,469.19
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,273.21
|
| Rate for Payer: UHC Exchange |
$1,469.19
|
| Rate for Payer: UHC Medicare Advantage |
$1,273.21
|
| Rate for Payer: UHCCP Medicaid |
$716.82
|
| Rate for Payer: VA VA |
$1,273.21
|
|
|
HC NM TUMOR LOCALIZATION SPECT 2 AREAS
|
Facility
|
IP
|
$1,985.39
|
|
|
Service Code
|
CPT 78831
|
| Hospital Charge Code |
34100081
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$1,250.80 |
| Max. Negotiated Rate |
$1,786.85 |
| Rate for Payer: Aetna Commercial |
$1,687.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,290.50
|
| Rate for Payer: Cash Price |
$1,588.31
|
| Rate for Payer: Cofinity Commercial |
$1,389.77
|
| Rate for Payer: Cofinity Commercial |
$1,707.44
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,389.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,588.31
|
| Rate for Payer: Healthscope Commercial |
$1,786.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,687.58
|
| Rate for Payer: PHP Commercial |
$1,687.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,290.50
|
| Rate for Payer: Priority Health SBD |
$1,250.80
|
|
|
HC NM TUMOR SCAN SPECT
|
Facility
|
OP
|
$1,975.72
|
|
|
Service Code
|
CPT 78803
|
| Hospital Charge Code |
34100056
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$682.44 |
| Max. Negotiated Rate |
$3,583.96 |
| Rate for Payer: Aetna Commercial |
$1,679.36
|
| Rate for Payer: Aetna Medicare |
$1,324.14
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,284.22
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1,591.51
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1,591.51
|
| Rate for Payer: BCBS Complete |
$716.56
|
| Rate for Payer: BCBS MAPPO |
$1,273.21
|
| Rate for Payer: BCN Medicare Advantage |
$1,273.21
|
| Rate for Payer: Cash Price |
$1,580.58
|
| Rate for Payer: Cash Price |
$1,580.58
|
| Rate for Payer: Cofinity Commercial |
$1,699.12
|
| Rate for Payer: Cofinity Commercial |
$1,383.00
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,383.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,580.58
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,273.21
|
| Rate for Payer: Healthscope Commercial |
$1,778.15
|
| Rate for Payer: Mclaren Medicaid |
$682.44
|
| Rate for Payer: Mclaren Medicare |
$1,273.21
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,336.87
|
| Rate for Payer: Meridian Medicaid |
$716.56
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,464.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,679.36
|
| Rate for Payer: PACE Medicare |
$1,209.55
|
| Rate for Payer: PACE SWMI |
$1,273.21
|
| Rate for Payer: PHP Commercial |
$1,679.36
|
| Rate for Payer: PHP Medicare Advantage |
$1,273.21
|
| Rate for Payer: Priority Health Choice Medicaid |
$682.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,284.22
|
| Rate for Payer: Priority Health Medicare |
$1,273.21
|
| Rate for Payer: Priority Health SBD |
$1,244.70
|
| Rate for Payer: Railroad Medicare Medicare |
$1,273.21
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3,583.96
|
| Rate for Payer: UHC Core |
$1,462.03
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,273.21
|
| Rate for Payer: UHC Exchange |
$1,462.03
|
| Rate for Payer: UHC Medicare Advantage |
$1,273.21
|
| Rate for Payer: UHCCP Medicaid |
$716.82
|
| Rate for Payer: VA VA |
$1,273.21
|
|
|
HC NM TUMOR SCAN SPECT
|
Facility
|
IP
|
$1,975.72
|
|
|
Service Code
|
CPT 78803
|
| Hospital Charge Code |
34100056
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$1,244.70 |
| Max. Negotiated Rate |
$1,778.15 |
| Rate for Payer: Aetna Commercial |
$1,679.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,284.22
|
| Rate for Payer: Cash Price |
$1,580.58
|
| Rate for Payer: Cofinity Commercial |
$1,383.00
|
| Rate for Payer: Cofinity Commercial |
$1,699.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,383.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,580.58
|
| Rate for Payer: Healthscope Commercial |
$1,778.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,679.36
|
| Rate for Payer: PHP Commercial |
$1,679.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,284.22
|
| Rate for Payer: Priority Health SBD |
$1,244.70
|
|
|
HC NM UNLISTED PROC ENDOCRINE S
|
Facility
|
IP
|
$1,757.18
|
|
|
Service Code
|
CPT 60699
|
| Hospital Charge Code |
36100267
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,107.02 |
| Max. Negotiated Rate |
$1,581.46 |
| Rate for Payer: Aetna Commercial |
$1,493.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,142.17
|
| Rate for Payer: Cash Price |
$1,405.74
|
| Rate for Payer: Cofinity Commercial |
$1,230.03
|
| Rate for Payer: Cofinity Commercial |
$1,511.17
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,230.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,405.74
|
| Rate for Payer: Healthscope Commercial |
$1,581.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,493.60
|
| Rate for Payer: PHP Commercial |
$1,493.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,142.17
|
| Rate for Payer: Priority Health SBD |
$1,107.02
|
|
|
HC NM UNLISTED PROC ENDOCRINE S
|
Facility
|
OP
|
$1,757.18
|
|
|
Service Code
|
CPT 60699
|
| Hospital Charge Code |
36100267
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,107.02 |
| Max. Negotiated Rate |
$16,017.15 |
| Rate for Payer: Aetna Commercial |
$1,493.60
|
| Rate for Payer: Aetna Medicare |
$5,917.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,142.17
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7,112.66
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7,112.66
|
| Rate for Payer: BCBS Complete |
$3,202.41
|
| Rate for Payer: BCBS MAPPO |
$5,690.13
|
| Rate for Payer: BCN Medicare Advantage |
$5,690.13
|
| Rate for Payer: Cash Price |
$1,405.74
|
| Rate for Payer: Cash Price |
$1,405.74
|
| Rate for Payer: Cofinity Commercial |
$1,511.17
|
| Rate for Payer: Cofinity Commercial |
$1,230.03
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,230.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,405.74
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5,690.13
|
| Rate for Payer: Healthscope Commercial |
$1,581.46
|
| Rate for Payer: Mclaren Medicaid |
$3,049.91
|
| Rate for Payer: Mclaren Medicare |
$5,690.13
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5,974.64
|
| Rate for Payer: Meridian Medicaid |
$3,202.41
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6,543.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,493.60
|
| Rate for Payer: PACE Medicare |
$5,405.62
|
| Rate for Payer: PACE SWMI |
$5,690.13
|
| Rate for Payer: PHP Commercial |
$1,493.60
|
| Rate for Payer: PHP Medicare Advantage |
$5,690.13
|
| Rate for Payer: Priority Health Choice Medicaid |
$3,049.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,142.17
|
| Rate for Payer: Priority Health Medicare |
$5,690.13
|
| Rate for Payer: Priority Health SBD |
$1,107.02
|
| Rate for Payer: Railroad Medicare Medicare |
$5,690.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$16,017.15
|
| Rate for Payer: UHC Dual Complete DSNP |
$5,690.13
|
| Rate for Payer: UHC Medicare Advantage |
$5,690.13
|
| Rate for Payer: UHCCP Medicaid |
$3,203.54
|
| Rate for Payer: VA VA |
$5,690.13
|
|
|
HC NM VENT AEROSOL/GAS AND PERFUS
|
Facility
|
IP
|
$1,666.35
|
|
|
Service Code
|
CPT 78582
|
| Hospital Charge Code |
34100068
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$1,049.80 |
| Max. Negotiated Rate |
$1,499.71 |
| Rate for Payer: Aetna Commercial |
$1,416.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,083.13
|
| Rate for Payer: Cash Price |
$1,333.08
|
| Rate for Payer: Cofinity Commercial |
$1,166.44
|
| Rate for Payer: Cofinity Commercial |
$1,433.06
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,166.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,333.08
|
| Rate for Payer: Healthscope Commercial |
$1,499.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,416.40
|
| Rate for Payer: PHP Commercial |
$1,416.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,083.13
|
| Rate for Payer: Priority Health SBD |
$1,049.80
|
|
|
HC NM VENT AEROSOL/GAS AND PERFUS
|
Facility
|
OP
|
$1,666.35
|
|
|
Service Code
|
CPT 78582
|
| Hospital Charge Code |
34100068
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$281.38 |
| Max. Negotiated Rate |
$1,499.71 |
| Rate for Payer: Aetna Commercial |
$1,416.40
|
| Rate for Payer: Aetna Medicare |
$545.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,083.13
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$656.20
|
| Rate for Payer: Amish Plain Church Group Commercial |
$656.20
|
| Rate for Payer: BCBS Complete |
$295.45
|
| Rate for Payer: BCBS MAPPO |
$524.96
|
| Rate for Payer: BCN Medicare Advantage |
$524.96
|
| Rate for Payer: Cash Price |
$1,333.08
|
| Rate for Payer: Cash Price |
$1,333.08
|
| Rate for Payer: Cofinity Commercial |
$1,433.06
|
| Rate for Payer: Cofinity Commercial |
$1,166.44
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,166.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,333.08
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$524.96
|
| Rate for Payer: Healthscope Commercial |
$1,499.71
|
| Rate for Payer: Mclaren Medicaid |
$281.38
|
| Rate for Payer: Mclaren Medicare |
$524.96
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$551.21
|
| Rate for Payer: Meridian Medicaid |
$295.45
|
| Rate for Payer: MI Amish Medical Board Commercial |
$603.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,416.40
|
| Rate for Payer: PACE Medicare |
$498.71
|
| Rate for Payer: PACE SWMI |
$524.96
|
| Rate for Payer: PHP Commercial |
$1,416.40
|
| Rate for Payer: PHP Medicare Advantage |
$524.96
|
| Rate for Payer: Priority Health Choice Medicaid |
$281.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,083.13
|
| Rate for Payer: Priority Health Medicare |
$524.96
|
| Rate for Payer: Priority Health SBD |
$1,049.80
|
| Rate for Payer: Railroad Medicare Medicare |
$524.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,477.71
|
| Rate for Payer: UHC Core |
$1,233.10
|
| Rate for Payer: UHC Dual Complete DSNP |
$524.96
|
| Rate for Payer: UHC Exchange |
$1,233.10
|
| Rate for Payer: UHC Medicare Advantage |
$524.96
|
| Rate for Payer: UHCCP Medicaid |
$295.55
|
| Rate for Payer: VA VA |
$524.96
|
|
|
HC NM VENTILATION AEROSOL OR GAS
|
Facility
|
OP
|
$1,219.18
|
|
|
Service Code
|
CPT 78579
|
| Hospital Charge Code |
34100071
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$210.06 |
| Max. Negotiated Rate |
$1,103.16 |
| Rate for Payer: Aetna Commercial |
$1,036.30
|
| Rate for Payer: Aetna Medicare |
$407.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$792.47
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$489.88
|
| Rate for Payer: Amish Plain Church Group Commercial |
$489.88
|
| Rate for Payer: BCBS Complete |
$220.56
|
| Rate for Payer: BCBS MAPPO |
$391.90
|
| Rate for Payer: BCN Medicare Advantage |
$391.90
|
| Rate for Payer: Cash Price |
$975.34
|
| Rate for Payer: Cash Price |
$975.34
|
| Rate for Payer: Cofinity Commercial |
$853.43
|
| Rate for Payer: Cofinity Commercial |
$1,048.49
|
| Rate for Payer: Cofinity Medicare Advantage |
$853.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$975.34
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$391.90
|
| Rate for Payer: Healthscope Commercial |
$1,097.26
|
| Rate for Payer: Mclaren Medicaid |
$210.06
|
| Rate for Payer: Mclaren Medicare |
$391.90
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$411.50
|
| Rate for Payer: Meridian Medicaid |
$220.56
|
| Rate for Payer: MI Amish Medical Board Commercial |
$450.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,036.30
|
| Rate for Payer: PACE Medicare |
$372.31
|
| Rate for Payer: PACE SWMI |
$391.90
|
| Rate for Payer: PHP Commercial |
$1,036.30
|
| Rate for Payer: PHP Medicare Advantage |
$391.90
|
| Rate for Payer: Priority Health Choice Medicaid |
$210.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$792.47
|
| Rate for Payer: Priority Health Medicare |
$391.90
|
| Rate for Payer: Priority Health SBD |
$768.08
|
| Rate for Payer: Railroad Medicare Medicare |
$391.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,103.16
|
| Rate for Payer: UHC Core |
$902.19
|
| Rate for Payer: UHC Dual Complete DSNP |
$391.90
|
| Rate for Payer: UHC Exchange |
$902.19
|
| Rate for Payer: UHC Medicare Advantage |
$391.90
|
| Rate for Payer: UHCCP Medicaid |
$220.64
|
| Rate for Payer: VA VA |
$391.90
|
|
|
HC NM VENTILATION AEROSOL OR GAS
|
Facility
|
IP
|
$1,219.18
|
|
|
Service Code
|
CPT 78579
|
| Hospital Charge Code |
34100071
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$768.08 |
| Max. Negotiated Rate |
$1,097.26 |
| Rate for Payer: Aetna Commercial |
$1,036.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$792.47
|
| Rate for Payer: Cash Price |
$975.34
|
| Rate for Payer: Cofinity Commercial |
$1,048.49
|
| Rate for Payer: Cofinity Commercial |
$853.43
|
| Rate for Payer: Cofinity Medicare Advantage |
$853.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$975.34
|
| Rate for Payer: Healthscope Commercial |
$1,097.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,036.30
|
| Rate for Payer: PHP Commercial |
$1,036.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$792.47
|
| Rate for Payer: Priority Health SBD |
$768.08
|
|
|
HC NM VENTILATION PERFUS QUANT DIFF
|
Facility
|
IP
|
$1,666.35
|
|
|
Service Code
|
CPT 78598
|
| Hospital Charge Code |
34100070
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$1,049.80 |
| Max. Negotiated Rate |
$1,499.71 |
| Rate for Payer: Aetna Commercial |
$1,416.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,083.13
|
| Rate for Payer: Cash Price |
$1,333.08
|
| Rate for Payer: Cofinity Commercial |
$1,166.44
|
| Rate for Payer: Cofinity Commercial |
$1,433.06
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,166.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,333.08
|
| Rate for Payer: Healthscope Commercial |
$1,499.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,416.40
|
| Rate for Payer: PHP Commercial |
$1,416.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,083.13
|
| Rate for Payer: Priority Health SBD |
$1,049.80
|
|
|
HC NM VENTILATION PERFUS QUANT DIFF
|
Facility
|
OP
|
$1,666.35
|
|
|
Service Code
|
CPT 78598
|
| Hospital Charge Code |
34100070
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$281.38 |
| Max. Negotiated Rate |
$1,499.71 |
| Rate for Payer: Aetna Commercial |
$1,416.40
|
| Rate for Payer: Aetna Medicare |
$545.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,083.13
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$656.20
|
| Rate for Payer: Amish Plain Church Group Commercial |
$656.20
|
| Rate for Payer: BCBS Complete |
$295.45
|
| Rate for Payer: BCBS MAPPO |
$524.96
|
| Rate for Payer: BCN Medicare Advantage |
$524.96
|
| Rate for Payer: Cash Price |
$1,333.08
|
| Rate for Payer: Cash Price |
$1,333.08
|
| Rate for Payer: Cofinity Commercial |
$1,433.06
|
| Rate for Payer: Cofinity Commercial |
$1,166.44
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,166.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,333.08
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$524.96
|
| Rate for Payer: Healthscope Commercial |
$1,499.71
|
| Rate for Payer: Mclaren Medicaid |
$281.38
|
| Rate for Payer: Mclaren Medicare |
$524.96
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$551.21
|
| Rate for Payer: Meridian Medicaid |
$295.45
|
| Rate for Payer: MI Amish Medical Board Commercial |
$603.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,416.40
|
| Rate for Payer: PACE Medicare |
$498.71
|
| Rate for Payer: PACE SWMI |
$524.96
|
| Rate for Payer: PHP Commercial |
$1,416.40
|
| Rate for Payer: PHP Medicare Advantage |
$524.96
|
| Rate for Payer: Priority Health Choice Medicaid |
$281.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,083.13
|
| Rate for Payer: Priority Health Medicare |
$524.96
|
| Rate for Payer: Priority Health SBD |
$1,049.80
|
| Rate for Payer: Railroad Medicare Medicare |
$524.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,477.71
|
| Rate for Payer: UHC Core |
$1,233.10
|
| Rate for Payer: UHC Dual Complete DSNP |
$524.96
|
| Rate for Payer: UHC Exchange |
$1,233.10
|
| Rate for Payer: UHC Medicare Advantage |
$524.96
|
| Rate for Payer: UHCCP Medicaid |
$295.55
|
| Rate for Payer: VA VA |
$524.96
|
|
|
HC NM VOID CYSTO
|
Facility
|
OP
|
$1,069.28
|
|
|
Service Code
|
CPT 78740
|
| Hospital Charge Code |
34100049
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$210.06 |
| Max. Negotiated Rate |
$1,103.16 |
| Rate for Payer: Aetna Commercial |
$908.89
|
| Rate for Payer: Aetna Medicare |
$407.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$695.03
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$489.88
|
| Rate for Payer: Amish Plain Church Group Commercial |
$489.88
|
| Rate for Payer: BCBS Complete |
$220.56
|
| Rate for Payer: BCBS MAPPO |
$391.90
|
| Rate for Payer: BCN Medicare Advantage |
$391.90
|
| Rate for Payer: Cash Price |
$855.42
|
| Rate for Payer: Cash Price |
$855.42
|
| Rate for Payer: Cofinity Commercial |
$919.58
|
| Rate for Payer: Cofinity Commercial |
$748.50
|
| Rate for Payer: Cofinity Medicare Advantage |
$748.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$855.42
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$391.90
|
| Rate for Payer: Healthscope Commercial |
$962.35
|
| Rate for Payer: Mclaren Medicaid |
$210.06
|
| Rate for Payer: Mclaren Medicare |
$391.90
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$411.50
|
| Rate for Payer: Meridian Medicaid |
$220.56
|
| Rate for Payer: MI Amish Medical Board Commercial |
$450.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$908.89
|
| Rate for Payer: PACE Medicare |
$372.31
|
| Rate for Payer: PACE SWMI |
$391.90
|
| Rate for Payer: PHP Commercial |
$908.89
|
| Rate for Payer: PHP Medicare Advantage |
$391.90
|
| Rate for Payer: Priority Health Choice Medicaid |
$210.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$695.03
|
| Rate for Payer: Priority Health Medicare |
$391.90
|
| Rate for Payer: Priority Health SBD |
$673.65
|
| Rate for Payer: Railroad Medicare Medicare |
$391.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,103.16
|
| Rate for Payer: UHC Core |
$791.27
|
| Rate for Payer: UHC Dual Complete DSNP |
$391.90
|
| Rate for Payer: UHC Exchange |
$791.27
|
| Rate for Payer: UHC Medicare Advantage |
$391.90
|
| Rate for Payer: UHCCP Medicaid |
$220.64
|
| Rate for Payer: VA VA |
$391.90
|
|
|
HC NM VOID CYSTO
|
Facility
|
IP
|
$1,069.28
|
|
|
Service Code
|
CPT 78740
|
| Hospital Charge Code |
34100049
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$673.65 |
| Max. Negotiated Rate |
$962.35 |
| Rate for Payer: Aetna Commercial |
$908.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$695.03
|
| Rate for Payer: Cash Price |
$855.42
|
| Rate for Payer: Cofinity Commercial |
$748.50
|
| Rate for Payer: Cofinity Commercial |
$919.58
|
| Rate for Payer: Cofinity Medicare Advantage |
$748.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$855.42
|
| Rate for Payer: Healthscope Commercial |
$962.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$908.89
|
| Rate for Payer: PHP Commercial |
$908.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$695.03
|
| Rate for Payer: Priority Health SBD |
$673.65
|
|
|
HC NM ZEVALIN Y-90 THERAPY
|
Facility
|
OP
|
$1,939.87
|
|
|
Service Code
|
CPT 79403
|
| Hospital Charge Code |
34100065
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$117.16 |
| Max. Negotiated Rate |
$1,745.88 |
| Rate for Payer: Aetna Commercial |
$1,648.89
|
| Rate for Payer: Aetna Medicare |
$227.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,260.92
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$273.24
|
| Rate for Payer: Amish Plain Church Group Commercial |
$273.24
|
| Rate for Payer: BCBS Complete |
$123.02
|
| Rate for Payer: BCBS MAPPO |
$218.59
|
| Rate for Payer: BCN Medicare Advantage |
$218.59
|
| Rate for Payer: Cash Price |
$1,551.90
|
| Rate for Payer: Cash Price |
$1,551.90
|
| Rate for Payer: Cofinity Commercial |
$1,668.29
|
| Rate for Payer: Cofinity Commercial |
$1,357.91
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,357.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,551.90
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$218.59
|
| Rate for Payer: Healthscope Commercial |
$1,745.88
|
| Rate for Payer: Mclaren Medicaid |
$117.16
|
| Rate for Payer: Mclaren Medicare |
$218.59
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$229.52
|
| Rate for Payer: Meridian Medicaid |
$123.02
|
| Rate for Payer: MI Amish Medical Board Commercial |
$251.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,648.89
|
| Rate for Payer: PACE Medicare |
$207.66
|
| Rate for Payer: PACE SWMI |
$218.59
|
| Rate for Payer: PHP Commercial |
$1,648.89
|
| Rate for Payer: PHP Medicare Advantage |
$218.59
|
| Rate for Payer: Priority Health Choice Medicaid |
$117.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,260.92
|
| Rate for Payer: Priority Health Medicare |
$218.59
|
| Rate for Payer: Priority Health SBD |
$1,222.12
|
| Rate for Payer: Railroad Medicare Medicare |
$218.59
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$615.31
|
| Rate for Payer: UHC Core |
$1,435.50
|
| Rate for Payer: UHC Dual Complete DSNP |
$218.59
|
| Rate for Payer: UHC Exchange |
$1,435.50
|
| Rate for Payer: UHC Medicare Advantage |
$218.59
|
| Rate for Payer: UHCCP Medicaid |
$123.07
|
| Rate for Payer: VA VA |
$218.59
|
|
|
HC NM ZEVALIN Y-90 THERAPY
|
Facility
|
IP
|
$1,939.87
|
|
|
Service Code
|
CPT 79403
|
| Hospital Charge Code |
34100065
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$1,222.12 |
| Max. Negotiated Rate |
$1,745.88 |
| Rate for Payer: Aetna Commercial |
$1,648.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,260.92
|
| Rate for Payer: Cash Price |
$1,551.90
|
| Rate for Payer: Cofinity Commercial |
$1,357.91
|
| Rate for Payer: Cofinity Commercial |
$1,668.29
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,357.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,551.90
|
| Rate for Payer: Healthscope Commercial |
$1,745.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,648.89
|
| Rate for Payer: PHP Commercial |
$1,648.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,260.92
|
| Rate for Payer: Priority Health SBD |
$1,222.12
|
|
|
HC NO IMPLANT/INSERT DEVICE W/DEVICE-INTENS PROC
|
Facility
|
OP
|
$1.02
|
|
|
Service Code
|
HCPCS C1890
|
| Hospital Charge Code |
27800125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$0.92 |
| Rate for Payer: Aetna Commercial |
$0.87
|
| Rate for Payer: Aetna Medicare |
$0.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.66
|
| Rate for Payer: BCBS Complete |
$0.41
|
| Rate for Payer: Cash Price |
$0.82
|
| Rate for Payer: Cofinity Commercial |
$0.71
|
| Rate for Payer: Cofinity Commercial |
$0.88
|
| Rate for Payer: Cofinity Medicare Advantage |
$0.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$0.82
|
| Rate for Payer: Healthscope Commercial |
$0.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$0.87
|
| Rate for Payer: PHP Commercial |
$0.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.66
|
| Rate for Payer: Priority Health SBD |
$0.64
|
|
|
HC NO IMPLANT/INSERT DEVICE W/DEVICE-INTENS PROC
|
Facility
|
IP
|
$1.02
|
|
|
Service Code
|
HCPCS C1890
|
| Hospital Charge Code |
27800125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$0.92 |
| Rate for Payer: Aetna Commercial |
$0.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.66
|
| Rate for Payer: Cash Price |
$0.82
|
| Rate for Payer: Cofinity Commercial |
$0.71
|
| Rate for Payer: Cofinity Commercial |
$0.88
|
| Rate for Payer: Cofinity Medicare Advantage |
$0.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$0.82
|
| Rate for Payer: Healthscope Commercial |
$0.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$0.87
|
| Rate for Payer: PHP Commercial |
$0.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.66
|
| Rate for Payer: Priority Health SBD |
$0.64
|
|
|
HC NONCONC SLIDES W/INTERP
|
Facility
|
OP
|
$87.30
|
|
|
Service Code
|
CPT 88104
|
| Hospital Charge Code |
31100001
|
|
Hospital Revenue Code
|
311
|
| Min. Negotiated Rate |
$20.52 |
| Max. Negotiated Rate |
$107.75 |
| Rate for Payer: Aetna Commercial |
$74.20
|
| Rate for Payer: Aetna Medicare |
$39.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$56.74
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$47.85
|
| Rate for Payer: Amish Plain Church Group Commercial |
$47.85
|
| Rate for Payer: BCBS Complete |
$21.54
|
| Rate for Payer: BCBS MAPPO |
$38.28
|
| Rate for Payer: BCN Medicare Advantage |
$38.28
|
| Rate for Payer: Cash Price |
$69.84
|
| Rate for Payer: Cash Price |
$69.84
|
| Rate for Payer: Cofinity Commercial |
$75.08
|
| Rate for Payer: Cofinity Commercial |
$61.11
|
| Rate for Payer: Cofinity Medicare Advantage |
$61.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$69.84
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$38.28
|
| Rate for Payer: Healthscope Commercial |
$78.57
|
| Rate for Payer: Mclaren Medicaid |
$20.52
|
| Rate for Payer: Mclaren Medicare |
$38.28
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$40.19
|
| Rate for Payer: Meridian Medicaid |
$21.54
|
| Rate for Payer: MI Amish Medical Board Commercial |
$44.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$74.20
|
| Rate for Payer: PACE Medicare |
$36.37
|
| Rate for Payer: PACE SWMI |
$38.28
|
| Rate for Payer: PHP Commercial |
$74.20
|
| Rate for Payer: PHP Medicare Advantage |
$38.28
|
| Rate for Payer: Priority Health Choice Medicaid |
$20.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$56.74
|
| Rate for Payer: Priority Health Medicare |
$38.28
|
| Rate for Payer: Priority Health SBD |
$55.00
|
| Rate for Payer: Railroad Medicare Medicare |
$38.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$107.75
|
| Rate for Payer: UHC Dual Complete DSNP |
$38.28
|
| Rate for Payer: UHC Medicare Advantage |
$38.28
|
| Rate for Payer: UHCCP Medicaid |
$21.55
|
| Rate for Payer: VA VA |
$38.28
|
|
|
HC NONCONC SLIDES W/INTERP
|
Facility
|
IP
|
$87.30
|
|
|
Service Code
|
CPT 88104
|
| Hospital Charge Code |
31100001
|
|
Hospital Revenue Code
|
311
|
| Min. Negotiated Rate |
$55.00 |
| Max. Negotiated Rate |
$78.57 |
| Rate for Payer: Aetna Commercial |
$74.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$56.74
|
| Rate for Payer: Cash Price |
$69.84
|
| Rate for Payer: Cofinity Commercial |
$61.11
|
| Rate for Payer: Cofinity Commercial |
$75.08
|
| Rate for Payer: Cofinity Medicare Advantage |
$61.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$69.84
|
| Rate for Payer: Healthscope Commercial |
$78.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$74.20
|
| Rate for Payer: PHP Commercial |
$74.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$56.74
|
| Rate for Payer: Priority Health SBD |
$55.00
|
|
