|
HC PT EVAL MODERATE COMPLEXITY
|
Facility
|
IP
|
$291.83
|
|
|
Service Code
|
CPT 97162
|
| Hospital Charge Code |
42400007
|
|
Hospital Revenue Code
|
424
|
| Min. Negotiated Rate |
$183.85 |
| Max. Negotiated Rate |
$262.65 |
| Rate for Payer: Aetna Commercial |
$248.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$189.69
|
| Rate for Payer: Cash Price |
$233.46
|
| Rate for Payer: Cofinity Advantage |
$204.28
|
| Rate for Payer: Cofinity Commercial |
$250.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$233.46
|
| Rate for Payer: Healthscope Commercial |
$262.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$248.06
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$218.87
|
| Rate for Payer: PHP Commercial |
$248.06
|
| Rate for Payer: Priority Health SBD |
$183.85
|
|
|
HC PT MIX 1:1
|
Facility
|
IP
|
$71.85
|
|
|
Service Code
|
CPT 85611
|
| Hospital Charge Code |
30500107
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$45.27 |
| Max. Negotiated Rate |
$64.67 |
| Rate for Payer: Aetna Commercial |
$61.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$46.70
|
| Rate for Payer: Cash Price |
$57.48
|
| Rate for Payer: Cofinity Advantage |
$50.30
|
| Rate for Payer: Cofinity Commercial |
$61.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$57.48
|
| Rate for Payer: Healthscope Commercial |
$64.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$61.07
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$53.89
|
| Rate for Payer: PHP Commercial |
$61.07
|
| Rate for Payer: Priority Health SBD |
$45.27
|
|
|
HC PT MIX 1:1
|
Facility
|
OP
|
$71.85
|
|
|
Service Code
|
CPT 85611
|
| Hospital Charge Code |
30500107
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$2.06 |
| Max. Negotiated Rate |
$64.67 |
| Rate for Payer: Aetna Commercial |
$61.07
|
| Rate for Payer: Aetna Medicare |
$4.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$46.70
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4.92
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4.92
|
| Rate for Payer: BCBS Complete |
$2.16
|
| Rate for Payer: BCBS MAPPO |
$3.94
|
| Rate for Payer: BCBS Trust/PPO |
$4.21
|
| Rate for Payer: BCN Commercial |
$4.21
|
| Rate for Payer: BCN Medicare Advantage |
$3.94
|
| Rate for Payer: Cash Price |
$57.48
|
| Rate for Payer: Cash Price |
$57.48
|
| Rate for Payer: Cofinity Advantage |
$50.30
|
| Rate for Payer: Cofinity Commercial |
$61.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$57.48
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3.94
|
| Rate for Payer: Healthscope Commercial |
$64.67
|
| Rate for Payer: Mclaren Medicaid |
$2.06
|
| Rate for Payer: Mclaren Medicare |
$3.94
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$4.14
|
| Rate for Payer: Meridian Medicaid |
$4.14
|
| Rate for Payer: MI Amish Medical Board Commercial |
$4.53
|
| Rate for Payer: Molina Medicare/Medicaid |
$4.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$61.07
|
| Rate for Payer: Nomi Health Commercial |
$5.91
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$53.89
|
| Rate for Payer: PACE Medicare |
$3.74
|
| Rate for Payer: PACE SWMI |
$3.94
|
| Rate for Payer: PHP Commercial |
$61.07
|
| Rate for Payer: PHP Medicare Advantage |
$3.94
|
| Rate for Payer: Priority Health Choice Medicaid |
$2.06
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$3.94
|
| Rate for Payer: Priority Health Medicare |
$3.94
|
| Rate for Payer: Priority Health SBD |
$45.27
|
| Rate for Payer: Priority Health Tiered Network |
$3.15
|
| Rate for Payer: Railroad Medicare Medicare |
$3.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$5.91
|
| Rate for Payer: UHC Core |
$5.91
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$3.94
|
| Rate for Payer: UHC Exchange |
$5.91
|
| Rate for Payer: UHC Medicaid |
$2.06
|
| Rate for Payer: UHCCP Medicaid |
$2.06
|
| Rate for Payer: VA VA |
$3.94
|
|
|
HC PT NEUROSTIM
|
Facility
|
OP
|
$99.08
|
|
|
Service Code
|
CPT 97032
|
| Hospital Charge Code |
42000007
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$12.80 |
| Max. Negotiated Rate |
$135.00 |
| Rate for Payer: Aetna Commercial |
$84.22
|
| Rate for Payer: Aetna Medicare |
$49.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$64.40
|
| Rate for Payer: BCBS Complete |
$39.63
|
| Rate for Payer: BCBS Trust/PPO |
$13.40
|
| Rate for Payer: BCN Commercial |
$13.40
|
| Rate for Payer: Cash Price |
$79.26
|
| Rate for Payer: Cash Price |
$79.26
|
| Rate for Payer: Cash Price |
$79.26
|
| Rate for Payer: Cofinity Advantage |
$69.36
|
| Rate for Payer: Cofinity Commercial |
$85.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$79.26
|
| Rate for Payer: Healthscope Commercial |
$89.17
|
| Rate for Payer: MI Amish Medical Board Commercial |
$79.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$84.22
|
| Rate for Payer: Nomi Health Commercial |
$135.00
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$74.31
|
| Rate for Payer: PHP Commercial |
$84.22
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$16.00
|
| Rate for Payer: Priority Health SBD |
$62.42
|
| Rate for Payer: Priority Health Tiered Network |
$12.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$64.40
|
| Rate for Payer: UHC Core |
$51.62
|
| Rate for Payer: UHC Exchange |
$38.94
|
|
|
HC PT NEUROSTIM
|
Facility
|
IP
|
$99.08
|
|
|
Service Code
|
CPT 97032
|
| Hospital Charge Code |
42000007
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$62.42 |
| Max. Negotiated Rate |
$89.17 |
| Rate for Payer: Aetna Commercial |
$84.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$64.40
|
| Rate for Payer: Cash Price |
$79.26
|
| Rate for Payer: Cofinity Advantage |
$69.36
|
| Rate for Payer: Cofinity Commercial |
$85.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$79.26
|
| Rate for Payer: Healthscope Commercial |
$89.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$84.22
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$74.31
|
| Rate for Payer: PHP Commercial |
$84.22
|
| Rate for Payer: Priority Health SBD |
$62.42
|
|
|
HC PT RE-EVALUATION
|
Facility
|
OP
|
$130.72
|
|
|
Service Code
|
CPT 97164
|
| Hospital Charge Code |
42400009
|
|
Hospital Revenue Code
|
424
|
| Min. Negotiated Rate |
$30.40 |
| Max. Negotiated Rate |
$135.00 |
| Rate for Payer: Aetna Commercial |
$111.11
|
| Rate for Payer: Aetna Medicare |
$65.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$84.97
|
| Rate for Payer: BCBS Complete |
$52.29
|
| Rate for Payer: BCBS Trust/PPO |
$55.04
|
| Rate for Payer: BCN Commercial |
$55.04
|
| Rate for Payer: Cash Price |
$104.58
|
| Rate for Payer: Cash Price |
$104.58
|
| Rate for Payer: Cash Price |
$104.58
|
| Rate for Payer: Cofinity Advantage |
$91.50
|
| Rate for Payer: Cofinity Commercial |
$112.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$104.58
|
| Rate for Payer: Healthscope Commercial |
$117.65
|
| Rate for Payer: MI Amish Medical Board Commercial |
$104.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$111.11
|
| Rate for Payer: Nomi Health Commercial |
$135.00
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$98.04
|
| Rate for Payer: PHP Commercial |
$111.11
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$38.00
|
| Rate for Payer: Priority Health SBD |
$82.35
|
| Rate for Payer: Priority Health Tiered Network |
$30.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$84.97
|
| Rate for Payer: UHC Core |
$68.11
|
| Rate for Payer: UHC Exchange |
$51.37
|
|
|
HC PT RE-EVALUATION
|
Facility
|
IP
|
$130.72
|
|
|
Service Code
|
CPT 97164
|
| Hospital Charge Code |
42400009
|
|
Hospital Revenue Code
|
424
|
| Min. Negotiated Rate |
$82.35 |
| Max. Negotiated Rate |
$117.65 |
| Rate for Payer: Aetna Commercial |
$111.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$84.97
|
| Rate for Payer: Cash Price |
$104.58
|
| Rate for Payer: Cofinity Advantage |
$91.50
|
| Rate for Payer: Cofinity Commercial |
$112.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$104.58
|
| Rate for Payer: Healthscope Commercial |
$117.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$111.11
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$98.04
|
| Rate for Payer: PHP Commercial |
$111.11
|
| Rate for Payer: Priority Health SBD |
$82.35
|
|
|
HC PULM EXER FUNCTION INDIV 15 MIN
|
Facility
|
OP
|
$89.43
|
|
|
Service Code
|
HCPCS G0238
|
| Hospital Charge Code |
41000045
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$14.09 |
| Max. Negotiated Rate |
$93.19 |
| Rate for Payer: Aetna Commercial |
$76.02
|
| Rate for Payer: Aetna Medicare |
$29.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$58.13
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$36.02
|
| Rate for Payer: Amish Plain Church Group Commercial |
$36.02
|
| Rate for Payer: BCBS Complete |
$15.83
|
| Rate for Payer: BCBS MAPPO |
$28.82
|
| Rate for Payer: BCBS Trust/PPO |
$14.09
|
| Rate for Payer: BCN Commercial |
$14.09
|
| Rate for Payer: BCN Medicare Advantage |
$28.82
|
| Rate for Payer: Cash Price |
$71.54
|
| Rate for Payer: Cash Price |
$71.54
|
| Rate for Payer: Cofinity Advantage |
$62.60
|
| Rate for Payer: Cofinity Commercial |
$76.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$71.54
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$28.82
|
| Rate for Payer: Healthscope Commercial |
$80.49
|
| Rate for Payer: Mclaren Medicaid |
$15.07
|
| Rate for Payer: Mclaren Medicare |
$28.82
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$30.26
|
| Rate for Payer: Meridian Medicaid |
$30.26
|
| Rate for Payer: MI Amish Medical Board Commercial |
$33.14
|
| Rate for Payer: Molina Medicare/Medicaid |
$31.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$76.02
|
| Rate for Payer: Nomi Health Commercial |
$86.46
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$67.07
|
| Rate for Payer: PACE Medicare |
$27.38
|
| Rate for Payer: PACE SWMI |
$28.82
|
| Rate for Payer: PHP Commercial |
$76.02
|
| Rate for Payer: PHP Medicare Advantage |
$28.82
|
| Rate for Payer: Priority Health Choice Medicaid |
$15.07
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$93.19
|
| Rate for Payer: Priority Health Medicare |
$28.82
|
| Rate for Payer: Priority Health SBD |
$56.34
|
| Rate for Payer: Priority Health Tiered Network |
$74.55
|
| Rate for Payer: Railroad Medicare Medicare |
$28.82
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$58.13
|
| Rate for Payer: UHC Core |
$46.59
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$28.82
|
| Rate for Payer: UHC Exchange |
$35.15
|
| Rate for Payer: UHC Medicaid |
$15.07
|
| Rate for Payer: UHCCP Medicaid |
$15.07
|
| Rate for Payer: VA VA |
$28.82
|
|
|
HC PULM EXER FUNCTION INDIV 15 MIN
|
Facility
|
IP
|
$89.43
|
|
|
Service Code
|
HCPCS G0238
|
| Hospital Charge Code |
41000045
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$56.34 |
| Max. Negotiated Rate |
$80.49 |
| Rate for Payer: Aetna Commercial |
$76.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$58.13
|
| Rate for Payer: Cash Price |
$71.54
|
| Rate for Payer: Cofinity Advantage |
$62.60
|
| Rate for Payer: Cofinity Commercial |
$76.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$71.54
|
| Rate for Payer: Healthscope Commercial |
$80.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$76.02
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$67.07
|
| Rate for Payer: PHP Commercial |
$76.02
|
| Rate for Payer: Priority Health SBD |
$56.34
|
|
|
HC PULMONARY ARTERIOGRAM NONSELECTIVE
|
Facility
|
IP
|
$1,735.21
|
|
|
Service Code
|
CPT 75746
|
| Hospital Charge Code |
32000197
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1,093.18 |
| Max. Negotiated Rate |
$1,561.69 |
| Rate for Payer: Aetna Commercial |
$1,474.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,127.89
|
| Rate for Payer: Cash Price |
$1,388.17
|
| Rate for Payer: Cofinity Advantage |
$1,214.65
|
| Rate for Payer: Cofinity Commercial |
$1,492.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,388.17
|
| Rate for Payer: Healthscope Commercial |
$1,561.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,474.93
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,301.41
|
| Rate for Payer: PHP Commercial |
$1,474.93
|
| Rate for Payer: Priority Health SBD |
$1,093.18
|
|
|
HC PULMONARY ARTERIOGRAM NONSELECTIVE
|
Facility
|
OP
|
$1,735.21
|
|
|
Service Code
|
CPT 75746
|
| Hospital Charge Code |
32000197
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$189.29 |
| Max. Negotiated Rate |
$10,174.29 |
| Rate for Payer: Aetna Commercial |
$1,474.93
|
| Rate for Payer: Aetna Medicare |
$3,271.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,127.89
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,932.66
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,932.66
|
| Rate for Payer: BCBS Complete |
$1,727.85
|
| Rate for Payer: BCBS MAPPO |
$3,146.13
|
| Rate for Payer: BCBS Trust/PPO |
$189.29
|
| Rate for Payer: BCN Commercial |
$189.29
|
| Rate for Payer: BCN Medicare Advantage |
$3,146.13
|
| Rate for Payer: Cash Price |
$1,388.17
|
| Rate for Payer: Cash Price |
$1,388.17
|
| Rate for Payer: Cofinity Advantage |
$1,214.65
|
| Rate for Payer: Cofinity Commercial |
$1,492.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,388.17
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,146.13
|
| Rate for Payer: Healthscope Commercial |
$1,561.69
|
| Rate for Payer: Mclaren Medicaid |
$1,645.43
|
| Rate for Payer: Mclaren Medicare |
$3,146.13
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,303.44
|
| Rate for Payer: Meridian Medicaid |
$3,303.44
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,618.05
|
| Rate for Payer: Molina Medicare/Medicaid |
$3,460.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,474.93
|
| Rate for Payer: Nomi Health Commercial |
$9,438.39
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,301.41
|
| Rate for Payer: PACE Medicare |
$2,988.82
|
| Rate for Payer: PACE SWMI |
$3,146.13
|
| Rate for Payer: PHP Commercial |
$1,474.93
|
| Rate for Payer: PHP Medicare Advantage |
$3,146.13
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,645.43
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$10,174.29
|
| Rate for Payer: Priority Health Medicare |
$3,146.13
|
| Rate for Payer: Priority Health SBD |
$1,093.18
|
| Rate for Payer: Priority Health Tiered Network |
$8,139.43
|
| Rate for Payer: Railroad Medicare Medicare |
$3,146.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,127.89
|
| Rate for Payer: UHC Core |
$904.04
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$3,146.13
|
| Rate for Payer: UHC Exchange |
$681.94
|
| Rate for Payer: UHC Medicaid |
$1,645.43
|
| Rate for Payer: UHCCP Medicaid |
$1,645.43
|
| Rate for Payer: VA VA |
$3,146.13
|
|
|
HC PULMONARY EXERCISE GROUP
|
Facility
|
OP
|
$107.30
|
|
|
Service Code
|
HCPCS G0239
|
| Hospital Charge Code |
41000044
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$19.47 |
| Max. Negotiated Rate |
$120.34 |
| Rate for Payer: Aetna Commercial |
$91.20
|
| Rate for Payer: Aetna Medicare |
$38.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$69.75
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$46.52
|
| Rate for Payer: Amish Plain Church Group Commercial |
$46.52
|
| Rate for Payer: BCBS Complete |
$20.44
|
| Rate for Payer: BCBS MAPPO |
$37.22
|
| Rate for Payer: BCBS Trust/PPO |
$57.73
|
| Rate for Payer: BCN Commercial |
$57.73
|
| Rate for Payer: BCN Medicare Advantage |
$37.22
|
| Rate for Payer: Cash Price |
$85.84
|
| Rate for Payer: Cash Price |
$85.84
|
| Rate for Payer: Cofinity Advantage |
$75.11
|
| Rate for Payer: Cofinity Commercial |
$92.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$85.84
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$37.22
|
| Rate for Payer: Healthscope Commercial |
$96.57
|
| Rate for Payer: Mclaren Medicaid |
$19.47
|
| Rate for Payer: Mclaren Medicare |
$37.22
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$39.08
|
| Rate for Payer: Meridian Medicaid |
$39.08
|
| Rate for Payer: MI Amish Medical Board Commercial |
$42.80
|
| Rate for Payer: Molina Medicare/Medicaid |
$40.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$91.20
|
| Rate for Payer: Nomi Health Commercial |
$111.66
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$80.47
|
| Rate for Payer: PACE Medicare |
$35.36
|
| Rate for Payer: PACE SWMI |
$37.22
|
| Rate for Payer: PHP Commercial |
$91.20
|
| Rate for Payer: PHP Medicare Advantage |
$37.22
|
| Rate for Payer: Priority Health Choice Medicaid |
$19.47
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$120.34
|
| Rate for Payer: Priority Health Medicare |
$37.22
|
| Rate for Payer: Priority Health SBD |
$67.60
|
| Rate for Payer: Priority Health Tiered Network |
$96.27
|
| Rate for Payer: Railroad Medicare Medicare |
$37.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$69.75
|
| Rate for Payer: UHC Core |
$55.90
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$37.22
|
| Rate for Payer: UHC Exchange |
$42.17
|
| Rate for Payer: UHC Medicaid |
$19.47
|
| Rate for Payer: UHCCP Medicaid |
$19.47
|
| Rate for Payer: VA VA |
$37.22
|
|
|
HC PULMONARY EXERCISE GROUP
|
Facility
|
IP
|
$107.30
|
|
|
Service Code
|
HCPCS G0239
|
| Hospital Charge Code |
41000044
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$67.60 |
| Max. Negotiated Rate |
$96.57 |
| Rate for Payer: Aetna Commercial |
$91.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$69.75
|
| Rate for Payer: Cash Price |
$85.84
|
| Rate for Payer: Cofinity Advantage |
$75.11
|
| Rate for Payer: Cofinity Commercial |
$92.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$85.84
|
| Rate for Payer: Healthscope Commercial |
$96.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$91.20
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$80.47
|
| Rate for Payer: PHP Commercial |
$91.20
|
| Rate for Payer: Priority Health SBD |
$67.60
|
|
|
HC PULMONARY STRESS TESTING (EG 6 MIN WALK)
|
Facility
|
IP
|
$379.26
|
|
|
Service Code
|
CPT 94618
|
| Hospital Charge Code |
46000030
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$238.93 |
| Max. Negotiated Rate |
$341.33 |
| Rate for Payer: Aetna Commercial |
$322.37
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$246.52
|
| Rate for Payer: Cash Price |
$303.41
|
| Rate for Payer: Cofinity Advantage |
$265.48
|
| Rate for Payer: Cofinity Commercial |
$326.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$303.41
|
| Rate for Payer: Healthscope Commercial |
$341.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$322.37
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$284.44
|
| Rate for Payer: PHP Commercial |
$322.37
|
| Rate for Payer: Priority Health SBD |
$238.93
|
|
|
HC PULMONARY STRESS TESTING (EG 6 MIN WALK)
|
Facility
|
OP
|
$379.26
|
|
|
Service Code
|
CPT 94618
|
| Hospital Charge Code |
46000030
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$56.26 |
| Max. Negotiated Rate |
$428.73 |
| Rate for Payer: Aetna Commercial |
$322.37
|
| Rate for Payer: Aetna Medicare |
$137.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$246.52
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$165.71
|
| Rate for Payer: Amish Plain Church Group Commercial |
$165.71
|
| Rate for Payer: BCBS Complete |
$72.81
|
| Rate for Payer: BCBS MAPPO |
$132.57
|
| Rate for Payer: BCBS Trust/PPO |
$56.26
|
| Rate for Payer: BCN Commercial |
$56.26
|
| Rate for Payer: BCN Medicare Advantage |
$132.57
|
| Rate for Payer: Cash Price |
$303.41
|
| Rate for Payer: Cash Price |
$303.41
|
| Rate for Payer: Cofinity Advantage |
$265.48
|
| Rate for Payer: Cofinity Commercial |
$326.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$303.41
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$132.57
|
| Rate for Payer: Healthscope Commercial |
$341.33
|
| Rate for Payer: Mclaren Medicaid |
$69.33
|
| Rate for Payer: Mclaren Medicare |
$132.57
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$139.20
|
| Rate for Payer: Meridian Medicaid |
$139.20
|
| Rate for Payer: MI Amish Medical Board Commercial |
$152.46
|
| Rate for Payer: Molina Medicare/Medicaid |
$145.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$322.37
|
| Rate for Payer: Nomi Health Commercial |
$397.71
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$284.44
|
| Rate for Payer: PACE Medicare |
$125.94
|
| Rate for Payer: PACE SWMI |
$132.57
|
| Rate for Payer: PHP Commercial |
$322.37
|
| Rate for Payer: PHP Medicare Advantage |
$132.57
|
| Rate for Payer: Priority Health Choice Medicaid |
$69.33
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$428.73
|
| Rate for Payer: Priority Health Medicare |
$132.57
|
| Rate for Payer: Priority Health SBD |
$238.93
|
| Rate for Payer: Priority Health Tiered Network |
$342.98
|
| Rate for Payer: Railroad Medicare Medicare |
$132.57
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$246.52
|
| Rate for Payer: UHC Core |
$197.59
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$132.57
|
| Rate for Payer: UHC Exchange |
$149.05
|
| Rate for Payer: UHC Medicaid |
$69.33
|
| Rate for Payer: UHCCP Medicaid |
$69.33
|
| Rate for Payer: VA VA |
$132.57
|
|
|
HC PULM REHAB W/ CONT OXIMTRY MNTR
|
Facility
|
OP
|
$263.50
|
|
|
Service Code
|
CPT 94626
|
| Hospital Charge Code |
94800004
|
|
Hospital Revenue Code
|
948
|
| Min. Negotiated Rate |
$30.74 |
| Max. Negotiated Rate |
$284.25 |
| Rate for Payer: Aetna Commercial |
$223.97
|
| Rate for Payer: Aetna Medicare |
$61.13
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$171.28
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$73.47
|
| Rate for Payer: Amish Plain Church Group Commercial |
$73.47
|
| Rate for Payer: BCBS Complete |
$32.28
|
| Rate for Payer: BCBS MAPPO |
$58.78
|
| Rate for Payer: BCBS Trust/PPO |
$284.25
|
| Rate for Payer: BCN Commercial |
$284.25
|
| Rate for Payer: BCN Medicare Advantage |
$58.78
|
| Rate for Payer: Cash Price |
$210.80
|
| Rate for Payer: Cash Price |
$210.80
|
| Rate for Payer: Cofinity Advantage |
$184.45
|
| Rate for Payer: Cofinity Commercial |
$226.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$210.80
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$58.78
|
| Rate for Payer: Healthscope Commercial |
$237.15
|
| Rate for Payer: Mclaren Medicaid |
$30.74
|
| Rate for Payer: Mclaren Medicare |
$58.78
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$61.72
|
| Rate for Payer: Meridian Medicaid |
$61.72
|
| Rate for Payer: MI Amish Medical Board Commercial |
$67.60
|
| Rate for Payer: Molina Medicare/Medicaid |
$64.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$223.97
|
| Rate for Payer: Nomi Health Commercial |
$176.34
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$197.62
|
| Rate for Payer: PACE Medicare |
$55.84
|
| Rate for Payer: PACE SWMI |
$58.78
|
| Rate for Payer: PHP Commercial |
$223.97
|
| Rate for Payer: PHP Medicare Advantage |
$58.78
|
| Rate for Payer: Priority Health Choice Medicaid |
$30.74
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$190.09
|
| Rate for Payer: Priority Health Medicare |
$58.78
|
| Rate for Payer: Priority Health SBD |
$166.00
|
| Rate for Payer: Priority Health Tiered Network |
$152.07
|
| Rate for Payer: Railroad Medicare Medicare |
$58.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$171.28
|
| Rate for Payer: UHC Core |
$137.28
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$58.78
|
| Rate for Payer: UHC Exchange |
$103.56
|
| Rate for Payer: UHC Medicaid |
$30.74
|
| Rate for Payer: UHCCP Medicaid |
$30.74
|
| Rate for Payer: VA VA |
$58.78
|
|
|
HC PULM REHAB W/ CONT OXIMTRY MNTR
|
Facility
|
IP
|
$263.50
|
|
|
Service Code
|
CPT 94626
|
| Hospital Charge Code |
94800004
|
|
Hospital Revenue Code
|
948
|
| Min. Negotiated Rate |
$166.00 |
| Max. Negotiated Rate |
$237.15 |
| Rate for Payer: Aetna Commercial |
$223.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$171.28
|
| Rate for Payer: Cash Price |
$210.80
|
| Rate for Payer: Cofinity Advantage |
$184.45
|
| Rate for Payer: Cofinity Commercial |
$226.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$210.80
|
| Rate for Payer: Healthscope Commercial |
$237.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$223.97
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$197.62
|
| Rate for Payer: PHP Commercial |
$223.97
|
| Rate for Payer: Priority Health SBD |
$166.00
|
|
|
HC PULM REHAB W/O CONT OXIMTRY MNTR
|
Facility
|
OP
|
$223.97
|
|
|
Service Code
|
CPT 94625
|
| Hospital Charge Code |
94800003
|
|
Hospital Revenue Code
|
948
|
| Min. Negotiated Rate |
$30.74 |
| Max. Negotiated Rate |
$284.25 |
| Rate for Payer: Aetna Commercial |
$190.37
|
| Rate for Payer: Aetna Medicare |
$61.13
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$145.58
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$73.47
|
| Rate for Payer: Amish Plain Church Group Commercial |
$73.47
|
| Rate for Payer: BCBS Complete |
$32.28
|
| Rate for Payer: BCBS MAPPO |
$58.78
|
| Rate for Payer: BCBS Trust/PPO |
$284.25
|
| Rate for Payer: BCN Commercial |
$284.25
|
| Rate for Payer: BCN Medicare Advantage |
$58.78
|
| Rate for Payer: Cash Price |
$179.18
|
| Rate for Payer: Cash Price |
$179.18
|
| Rate for Payer: Cofinity Advantage |
$156.78
|
| Rate for Payer: Cofinity Commercial |
$192.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$179.18
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$58.78
|
| Rate for Payer: Healthscope Commercial |
$201.57
|
| Rate for Payer: Mclaren Medicaid |
$30.74
|
| Rate for Payer: Mclaren Medicare |
$58.78
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$61.72
|
| Rate for Payer: Meridian Medicaid |
$61.72
|
| Rate for Payer: MI Amish Medical Board Commercial |
$67.60
|
| Rate for Payer: Molina Medicare/Medicaid |
$64.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$190.37
|
| Rate for Payer: Nomi Health Commercial |
$176.34
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$167.98
|
| Rate for Payer: PACE Medicare |
$55.84
|
| Rate for Payer: PACE SWMI |
$58.78
|
| Rate for Payer: PHP Commercial |
$190.37
|
| Rate for Payer: PHP Medicare Advantage |
$58.78
|
| Rate for Payer: Priority Health Choice Medicaid |
$30.74
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$190.09
|
| Rate for Payer: Priority Health Medicare |
$58.78
|
| Rate for Payer: Priority Health SBD |
$141.10
|
| Rate for Payer: Priority Health Tiered Network |
$152.07
|
| Rate for Payer: Railroad Medicare Medicare |
$58.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$145.58
|
| Rate for Payer: UHC Core |
$116.69
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$58.78
|
| Rate for Payer: UHC Exchange |
$88.02
|
| Rate for Payer: UHC Medicaid |
$30.74
|
| Rate for Payer: UHCCP Medicaid |
$30.74
|
| Rate for Payer: VA VA |
$58.78
|
|
|
HC PULM REHAB W/O CONT OXIMTRY MNTR
|
Facility
|
IP
|
$223.97
|
|
|
Service Code
|
CPT 94625
|
| Hospital Charge Code |
94800003
|
|
Hospital Revenue Code
|
948
|
| Min. Negotiated Rate |
$141.10 |
| Max. Negotiated Rate |
$201.57 |
| Rate for Payer: Aetna Commercial |
$190.37
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$145.58
|
| Rate for Payer: Cash Price |
$179.18
|
| Rate for Payer: Cofinity Advantage |
$156.78
|
| Rate for Payer: Cofinity Commercial |
$192.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$179.18
|
| Rate for Payer: Healthscope Commercial |
$201.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$190.37
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$167.98
|
| Rate for Payer: PHP Commercial |
$190.37
|
| Rate for Payer: Priority Health SBD |
$141.10
|
|
|
HC PULSE OXIMETRY MULTI DETER
|
Facility
|
IP
|
$130.80
|
|
|
Service Code
|
CPT 94761
|
| Hospital Charge Code |
46000012
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$82.40 |
| Max. Negotiated Rate |
$117.72 |
| Rate for Payer: Aetna Commercial |
$111.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$85.02
|
| Rate for Payer: Cash Price |
$104.64
|
| Rate for Payer: Cofinity Advantage |
$91.56
|
| Rate for Payer: Cofinity Commercial |
$112.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$104.64
|
| Rate for Payer: Healthscope Commercial |
$117.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$111.18
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$98.10
|
| Rate for Payer: PHP Commercial |
$111.18
|
| Rate for Payer: Priority Health SBD |
$82.40
|
|
|
HC PULSE OXIMETRY MULTI DETER
|
Facility
|
OP
|
$130.80
|
|
|
Service Code
|
CPT 94761
|
| Hospital Charge Code |
46000012
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$16.29 |
| Max. Negotiated Rate |
$117.72 |
| Rate for Payer: Aetna Commercial |
$111.18
|
| Rate for Payer: Aetna Medicare |
$65.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$85.02
|
| Rate for Payer: BCBS Complete |
$52.32
|
| Rate for Payer: BCBS Trust/PPO |
$16.29
|
| Rate for Payer: BCN Commercial |
$16.29
|
| Rate for Payer: Cash Price |
$104.64
|
| Rate for Payer: Cash Price |
$104.64
|
| Rate for Payer: Cofinity Advantage |
$91.56
|
| Rate for Payer: Cofinity Commercial |
$112.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$104.64
|
| Rate for Payer: Healthscope Commercial |
$117.72
|
| Rate for Payer: MI Amish Medical Board Commercial |
$104.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$111.18
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$98.10
|
| Rate for Payer: PHP Commercial |
$111.18
|
| Rate for Payer: Priority Health SBD |
$82.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$85.02
|
| Rate for Payer: UHC Core |
$68.15
|
| Rate for Payer: UHC Exchange |
$51.40
|
|
|
HC PULSE OX OVERNIGHT
|
Facility
|
OP
|
$209.53
|
|
|
Service Code
|
CPT 94762
|
| Hospital Charge Code |
46000027
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$67.05 |
| Max. Negotiated Rate |
$414.63 |
| Rate for Payer: Aetna Commercial |
$178.10
|
| Rate for Payer: Aetna Medicare |
$133.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$136.19
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$160.26
|
| Rate for Payer: Amish Plain Church Group Commercial |
$160.26
|
| Rate for Payer: BCBS Complete |
$70.41
|
| Rate for Payer: BCBS MAPPO |
$128.21
|
| Rate for Payer: BCBS Trust/PPO |
$108.07
|
| Rate for Payer: BCN Commercial |
$108.07
|
| Rate for Payer: BCN Medicare Advantage |
$128.21
|
| Rate for Payer: Cash Price |
$167.62
|
| Rate for Payer: Cash Price |
$167.62
|
| Rate for Payer: Cofinity Advantage |
$146.67
|
| Rate for Payer: Cofinity Commercial |
$180.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$167.62
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$128.21
|
| Rate for Payer: Healthscope Commercial |
$188.58
|
| Rate for Payer: Mclaren Medicaid |
$67.05
|
| Rate for Payer: Mclaren Medicare |
$128.21
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$134.62
|
| Rate for Payer: Meridian Medicaid |
$134.62
|
| Rate for Payer: MI Amish Medical Board Commercial |
$147.44
|
| Rate for Payer: Molina Medicare/Medicaid |
$141.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$178.10
|
| Rate for Payer: Nomi Health Commercial |
$384.63
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$157.15
|
| Rate for Payer: PACE Medicare |
$121.80
|
| Rate for Payer: PACE SWMI |
$128.21
|
| Rate for Payer: PHP Commercial |
$178.10
|
| Rate for Payer: PHP Medicare Advantage |
$128.21
|
| Rate for Payer: Priority Health Choice Medicaid |
$67.05
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$414.63
|
| Rate for Payer: Priority Health Medicare |
$128.21
|
| Rate for Payer: Priority Health SBD |
$132.00
|
| Rate for Payer: Priority Health Tiered Network |
$331.70
|
| Rate for Payer: Railroad Medicare Medicare |
$128.21
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$136.19
|
| Rate for Payer: UHC Core |
$109.17
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$128.21
|
| Rate for Payer: UHC Exchange |
$82.35
|
| Rate for Payer: UHC Medicaid |
$67.05
|
| Rate for Payer: UHCCP Medicaid |
$67.05
|
| Rate for Payer: VA VA |
$128.21
|
|
|
HC PULSE OX OVERNIGHT
|
Facility
|
IP
|
$209.53
|
|
|
Service Code
|
CPT 94762
|
| Hospital Charge Code |
46000027
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$132.00 |
| Max. Negotiated Rate |
$188.58 |
| Rate for Payer: Aetna Commercial |
$178.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$136.19
|
| Rate for Payer: Cash Price |
$167.62
|
| Rate for Payer: Cofinity Advantage |
$146.67
|
| Rate for Payer: Cofinity Commercial |
$180.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$167.62
|
| Rate for Payer: Healthscope Commercial |
$188.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$178.10
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$157.15
|
| Rate for Payer: PHP Commercial |
$178.10
|
| Rate for Payer: Priority Health SBD |
$132.00
|
|
|
HC PULSE OX SINGLE
|
Facility
|
IP
|
$88.16
|
|
|
Service Code
|
CPT 94760
|
| Hospital Charge Code |
46000026
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$55.54 |
| Max. Negotiated Rate |
$79.34 |
| Rate for Payer: Aetna Commercial |
$74.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$57.30
|
| Rate for Payer: Cash Price |
$70.53
|
| Rate for Payer: Cofinity Advantage |
$61.71
|
| Rate for Payer: Cofinity Commercial |
$75.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$70.53
|
| Rate for Payer: Healthscope Commercial |
$79.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$74.94
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$66.12
|
| Rate for Payer: PHP Commercial |
$74.94
|
| Rate for Payer: Priority Health SBD |
$55.54
|
|
|
HC PULSE OX SINGLE
|
Facility
|
OP
|
$88.16
|
|
|
Service Code
|
CPT 94760
|
| Hospital Charge Code |
46000026
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$14.82 |
| Max. Negotiated Rate |
$79.34 |
| Rate for Payer: Aetna Commercial |
$74.94
|
| Rate for Payer: Aetna Medicare |
$44.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$57.30
|
| Rate for Payer: BCBS Complete |
$35.26
|
| Rate for Payer: BCBS Trust/PPO |
$14.82
|
| Rate for Payer: BCN Commercial |
$14.82
|
| Rate for Payer: Cash Price |
$70.53
|
| Rate for Payer: Cash Price |
$70.53
|
| Rate for Payer: Cofinity Advantage |
$61.71
|
| Rate for Payer: Cofinity Commercial |
$75.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$70.53
|
| Rate for Payer: Healthscope Commercial |
$79.34
|
| Rate for Payer: MI Amish Medical Board Commercial |
$70.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$74.94
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$66.12
|
| Rate for Payer: PHP Commercial |
$74.94
|
| Rate for Payer: Priority Health SBD |
$55.54
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$57.30
|
| Rate for Payer: UHC Core |
$45.93
|
| Rate for Payer: UHC Exchange |
$34.65
|
|
