|
TRANEXAMIC ACID 650 MG TABLET
|
Facility
|
IP
|
$200.88
|
|
|
Service Code
|
NDC 72888017830
|
| Hospital Charge Code |
104576
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$88.39 |
| Max. Negotiated Rate |
$180.79 |
| Rate for Payer: Aetna American Axle |
$130.57
|
| Rate for Payer: Aetna Commercial |
$170.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$130.57
|
| Rate for Payer: Cash Price |
$160.70
|
| Rate for Payer: Cofinity Advantage |
$140.62
|
| Rate for Payer: Cofinity Commercial |
$172.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$160.70
|
| Rate for Payer: Healthscope Commercial |
$180.79
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$140.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$150.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$170.75
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$150.66
|
| Rate for Payer: PHP Commercial |
$170.75
|
| Rate for Payer: Priority Health SBD |
$126.55
|
| Rate for Payer: UMR Bronson Commercial |
$88.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$150.66
|
|
|
TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S) (EXCEPT LOWER EXTREMITY ARTERY(S) FOR OCCLUSIVE DISEASE, CERVICAL CAROTID, EXTRACRANIAL VERTEBRAL OR INTRATHORACIC CAROTID, INTRACRANIAL, OR CORONARY), OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION AND INCLUDING ALL ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED; INITIAL ARTERY
|
Facility
|
OP
|
$37,198.61
|
|
|
Service Code
|
CPT 37236
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$6,015.90 |
| Max. Negotiated Rate |
$37,198.61 |
| Rate for Payer: Aetna Medicare |
$11,962.79
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$14,378.35
|
| Rate for Payer: Amish Plain Church Group Commercial |
$14,378.35
|
| Rate for Payer: BCBS Complete |
$6,317.27
|
| Rate for Payer: BCBS MAPPO |
$11,502.68
|
| Rate for Payer: BCBS Trust/PPO |
$14,184.26
|
| Rate for Payer: BCN Commercial |
$14,184.26
|
| Rate for Payer: BCN Medicare Advantage |
$11,502.68
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$11,502.68
|
| Rate for Payer: Mclaren Medicaid |
$11,502.68
|
| Rate for Payer: Mclaren Medicare |
$11,502.68
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$12,077.81
|
| Rate for Payer: Meridian Medicaid |
$12,077.81
|
| Rate for Payer: MI Amish Medical Board Commercial |
$13,228.08
|
| Rate for Payer: Molina Medicare/Medicaid |
$12,652.95
|
| Rate for Payer: Nomi Health Commercial |
$34,508.04
|
| Rate for Payer: PACE Medicare |
$10,927.55
|
| Rate for Payer: PACE SWMI |
$11,502.68
|
| Rate for Payer: PHP Medicare Advantage |
$11,502.68
|
| Rate for Payer: Priority Health Choice Medicaid |
$6,015.90
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$37,198.61
|
| Rate for Payer: Priority Health Medicare |
$11,502.68
|
| Rate for Payer: Priority Health Tiered Network |
$29,758.89
|
| Rate for Payer: Railroad Medicare Medicare |
$11,502.68
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$11,502.68
|
| Rate for Payer: UHC Medicaid |
$6,015.90
|
| Rate for Payer: UHCCP Medicaid |
$6,015.90
|
| Rate for Payer: VA VA |
$11,502.68
|
|
|
TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S), OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION AND INCLUDING ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED; INITIAL VEIN
|
Facility
|
OP
|
$37,198.61
|
|
|
Service Code
|
CPT 37238
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$6,015.90 |
| Max. Negotiated Rate |
$37,198.61 |
| Rate for Payer: Aetna Medicare |
$11,962.79
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$14,378.35
|
| Rate for Payer: Amish Plain Church Group Commercial |
$14,378.35
|
| Rate for Payer: BCBS Complete |
$6,317.27
|
| Rate for Payer: BCBS MAPPO |
$11,502.68
|
| Rate for Payer: BCBS Trust/PPO |
$18,433.00
|
| Rate for Payer: BCN Commercial |
$18,433.00
|
| Rate for Payer: BCN Medicare Advantage |
$11,502.68
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$11,502.68
|
| Rate for Payer: Mclaren Medicaid |
$11,502.68
|
| Rate for Payer: Mclaren Medicare |
$11,502.68
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$12,077.81
|
| Rate for Payer: Meridian Medicaid |
$12,077.81
|
| Rate for Payer: MI Amish Medical Board Commercial |
$13,228.08
|
| Rate for Payer: Molina Medicare/Medicaid |
$12,652.95
|
| Rate for Payer: Nomi Health Commercial |
$34,508.04
|
| Rate for Payer: PACE Medicare |
$10,927.55
|
| Rate for Payer: PACE SWMI |
$11,502.68
|
| Rate for Payer: PHP Medicare Advantage |
$11,502.68
|
| Rate for Payer: Priority Health Choice Medicaid |
$6,015.90
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$37,198.61
|
| Rate for Payer: Priority Health Medicare |
$11,502.68
|
| Rate for Payer: Priority Health Tiered Network |
$29,758.89
|
| Rate for Payer: Railroad Medicare Medicare |
$11,502.68
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$11,502.68
|
| Rate for Payer: UHC Medicaid |
$6,015.90
|
| Rate for Payer: UHCCP Medicaid |
$6,015.90
|
| Rate for Payer: VA VA |
$11,502.68
|
|
|
TRANSCATHETER PLACEMENT OF INTRAVASCULAR STENT(S), CENTRAL DIALYSIS SEGMENT, PERFORMED THROUGH DIALYSIS CIRCUIT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION REQUIRED TO PERFORM THE STENTING, AND ALL ANGIOPLASTY IN THE CENTRAL DIALYSIS SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$11,576.19
|
|
|
Service Code
|
CPT 36908
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$11,576.19 |
| Max. Negotiated Rate |
$11,576.19 |
| Rate for Payer: BCBS Trust/PPO |
$11,576.19
|
| Rate for Payer: BCN Commercial |
$11,576.19
|
|
|
TRANSECTION OR AVULSION OF OTHER SPINAL NERVE, EXTRADURAL
|
Facility
|
OP
|
$6,292.24
|
|
|
Service Code
|
CPT 64772
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,017.60 |
| Max. Negotiated Rate |
$6,292.24 |
| Rate for Payer: Aetna Medicare |
$2,023.53
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,432.12
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,432.12
|
| Rate for Payer: BCBS Complete |
$1,068.58
|
| Rate for Payer: BCBS MAPPO |
$1,945.70
|
| Rate for Payer: BCBS Trust/PPO |
$1,917.37
|
| Rate for Payer: BCN Commercial |
$1,917.37
|
| Rate for Payer: BCN Medicare Advantage |
$1,945.70
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,945.70
|
| Rate for Payer: Mclaren Medicaid |
$1,945.70
|
| Rate for Payer: Mclaren Medicare |
$1,945.70
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$2,042.98
|
| Rate for Payer: Meridian Medicaid |
$2,042.98
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2,237.55
|
| Rate for Payer: Molina Medicare/Medicaid |
$2,140.27
|
| Rate for Payer: Nomi Health Commercial |
$5,837.10
|
| Rate for Payer: PACE Medicare |
$1,848.41
|
| Rate for Payer: PACE SWMI |
$1,945.70
|
| Rate for Payer: PHP Medicare Advantage |
$1,945.70
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,017.60
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$6,292.24
|
| Rate for Payer: Priority Health Medicare |
$1,945.70
|
| Rate for Payer: Priority Health Tiered Network |
$5,033.79
|
| Rate for Payer: Railroad Medicare Medicare |
$1,945.70
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$1,945.70
|
| Rate for Payer: UHC Medicaid |
$1,017.60
|
| Rate for Payer: UHCCP Medicaid |
$1,017.60
|
| Rate for Payer: VA VA |
$1,945.70
|
|
|
TRANSFER OR TRANSPLANT OF SINGLE TENDON (WITH MUSCLE REDIRECTION OR REROUTING); DEEP (EG, ANTERIOR TIBIAL OR POSTERIOR TIBIAL THROUGH INTEROSSEOUS SPACE, FLEXOR DIGITORUM LONGUS, FLEXOR HALLUCIS LONGUS, OR PERONEAL TENDON TO MIDFOOT OR HINDFOOT)
|
Facility
|
OP
|
$23,381.57
|
|
|
Service Code
|
CPT 27691
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,781.35 |
| Max. Negotiated Rate |
$23,381.57 |
| Rate for Payer: Aetna Medicare |
$7,519.32
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$9,037.65
|
| Rate for Payer: Amish Plain Church Group Commercial |
$9,037.65
|
| Rate for Payer: BCBS Complete |
$3,970.78
|
| Rate for Payer: BCBS MAPPO |
$7,230.12
|
| Rate for Payer: BCBS Trust/PPO |
$4,985.59
|
| Rate for Payer: BCN Commercial |
$4,985.59
|
| Rate for Payer: BCN Medicare Advantage |
$7,230.12
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$7,230.12
|
| Rate for Payer: Mclaren Medicaid |
$7,230.12
|
| Rate for Payer: Mclaren Medicare |
$7,230.12
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$7,591.63
|
| Rate for Payer: Meridian Medicaid |
$7,591.63
|
| Rate for Payer: MI Amish Medical Board Commercial |
$8,314.64
|
| Rate for Payer: Molina Medicare/Medicaid |
$7,953.13
|
| Rate for Payer: Nomi Health Commercial |
$21,690.36
|
| Rate for Payer: PACE Medicare |
$6,868.61
|
| Rate for Payer: PACE SWMI |
$7,230.12
|
| Rate for Payer: PHP Medicare Advantage |
$7,230.12
|
| Rate for Payer: Priority Health Choice Medicaid |
$3,781.35
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$23,381.57
|
| Rate for Payer: Priority Health Medicare |
$7,230.12
|
| Rate for Payer: Priority Health Tiered Network |
$18,705.26
|
| Rate for Payer: Railroad Medicare Medicare |
$7,230.12
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$7,230.12
|
| Rate for Payer: UHC Medicaid |
$3,781.35
|
| Rate for Payer: UHCCP Medicaid |
$3,781.35
|
| Rate for Payer: VA VA |
$7,230.12
|
|
|
TRANSFER OR TRANSPLANT OF SINGLE TENDON (WITH MUSCLE REDIRECTION OR REROUTING); SUPERFICIAL (EG, ANTERIOR TIBIAL EXTENSORS INTO MIDFOOT)
|
Facility
|
OP
|
$23,381.57
|
|
|
Service Code
|
CPT 27690
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,781.35 |
| Max. Negotiated Rate |
$23,381.57 |
| Rate for Payer: Aetna Medicare |
$7,519.32
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$9,037.65
|
| Rate for Payer: Amish Plain Church Group Commercial |
$9,037.65
|
| Rate for Payer: BCBS Complete |
$3,970.78
|
| Rate for Payer: BCBS MAPPO |
$7,230.12
|
| Rate for Payer: BCBS Trust/PPO |
$5,816.50
|
| Rate for Payer: BCN Commercial |
$5,816.50
|
| Rate for Payer: BCN Medicare Advantage |
$7,230.12
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$7,230.12
|
| Rate for Payer: Mclaren Medicaid |
$7,230.12
|
| Rate for Payer: Mclaren Medicare |
$7,230.12
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$7,591.63
|
| Rate for Payer: Meridian Medicaid |
$7,591.63
|
| Rate for Payer: MI Amish Medical Board Commercial |
$8,314.64
|
| Rate for Payer: Molina Medicare/Medicaid |
$7,953.13
|
| Rate for Payer: Nomi Health Commercial |
$21,690.36
|
| Rate for Payer: PACE Medicare |
$6,868.61
|
| Rate for Payer: PACE SWMI |
$7,230.12
|
| Rate for Payer: PHP Medicare Advantage |
$7,230.12
|
| Rate for Payer: Priority Health Choice Medicaid |
$3,781.35
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$23,381.57
|
| Rate for Payer: Priority Health Medicare |
$7,230.12
|
| Rate for Payer: Priority Health Tiered Network |
$18,705.26
|
| Rate for Payer: Railroad Medicare Medicare |
$7,230.12
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$7,230.12
|
| Rate for Payer: UHC Medicaid |
$3,781.35
|
| Rate for Payer: UHCCP Medicaid |
$3,781.35
|
| Rate for Payer: VA VA |
$7,230.12
|
|
|
TRANSFER OR TRANSPLANT OF TENDON, CARPOMETACARPAL AREA OR DORSUM OF HAND; WITHOUT FREE GRAFT, EACH TENDON
|
Facility
|
OP
|
$10,543.31
|
|
|
Service Code
|
CPT 26480
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,705.10 |
| Max. Negotiated Rate |
$10,543.31 |
| Rate for Payer: Aetna Medicare |
$3,390.64
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4,075.29
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4,075.29
|
| Rate for Payer: BCBS Complete |
$1,790.52
|
| Rate for Payer: BCBS MAPPO |
$3,260.23
|
| Rate for Payer: BCBS Trust/PPO |
$2,675.66
|
| Rate for Payer: BCN Commercial |
$2,675.66
|
| Rate for Payer: BCN Medicare Advantage |
$3,260.23
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,260.23
|
| Rate for Payer: Mclaren Medicaid |
$3,260.23
|
| Rate for Payer: Mclaren Medicare |
$3,260.23
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,423.24
|
| Rate for Payer: Meridian Medicaid |
$3,423.24
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,749.26
|
| Rate for Payer: Molina Medicare/Medicaid |
$3,586.25
|
| Rate for Payer: Nomi Health Commercial |
$9,780.69
|
| Rate for Payer: PACE Medicare |
$3,097.22
|
| Rate for Payer: PACE SWMI |
$3,260.23
|
| Rate for Payer: PHP Medicare Advantage |
$3,260.23
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,705.10
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$10,543.31
|
| Rate for Payer: Priority Health Medicare |
$3,260.23
|
| Rate for Payer: Priority Health Tiered Network |
$8,434.65
|
| Rate for Payer: Railroad Medicare Medicare |
$3,260.23
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$3,260.23
|
| Rate for Payer: UHC Medicaid |
$1,705.10
|
| Rate for Payer: UHCCP Medicaid |
$1,705.10
|
| Rate for Payer: VA VA |
$3,260.23
|
|
|
TRANSIENT ISCHEMIA
|
Facility
|
IP
|
$6,973.34
|
|
|
Service Code
|
APR-DRG 0473
|
| Min. Negotiated Rate |
$6,641.28 |
| Max. Negotiated Rate |
$6,973.34 |
| Rate for Payer: BCBS Complete |
$6,973.34
|
| Rate for Payer: Mclaren Medicaid |
$6,641.28
|
| Rate for Payer: Meridian Medicaid |
$6,973.34
|
| Rate for Payer: Priority Health Choice Medicaid |
$6,641.28
|
| Rate for Payer: UHC Medicaid |
$6,641.28
|
| Rate for Payer: UHCCP Medicaid |
$6,641.28
|
|
|
TRANSIENT ISCHEMIA
|
Facility
|
IP
|
$5,441.87
|
|
|
Service Code
|
APR-DRG 0472
|
| Min. Negotiated Rate |
$5,182.73 |
| Max. Negotiated Rate |
$5,441.87 |
| Rate for Payer: BCBS Complete |
$5,441.87
|
| Rate for Payer: Mclaren Medicaid |
$5,182.73
|
| Rate for Payer: Meridian Medicaid |
$5,441.87
|
| Rate for Payer: Priority Health Choice Medicaid |
$5,182.73
|
| Rate for Payer: UHC Medicaid |
$5,182.73
|
| Rate for Payer: UHCCP Medicaid |
$5,182.73
|
|
|
TRANSIENT ISCHEMIA
|
Facility
|
IP
|
$4,496.35
|
|
|
Service Code
|
APR-DRG 0471
|
| Min. Negotiated Rate |
$4,282.24 |
| Max. Negotiated Rate |
$4,496.35 |
| Rate for Payer: BCBS Complete |
$4,496.35
|
| Rate for Payer: Mclaren Medicaid |
$4,282.24
|
| Rate for Payer: Meridian Medicaid |
$4,496.35
|
| Rate for Payer: Priority Health Choice Medicaid |
$4,282.24
|
| Rate for Payer: UHC Medicaid |
$4,282.24
|
| Rate for Payer: UHCCP Medicaid |
$4,282.24
|
|
|
TRANSIENT ISCHEMIA
|
Facility
|
IP
|
$10,895.24
|
|
|
Service Code
|
APR-DRG 0474
|
| Min. Negotiated Rate |
$10,376.42 |
| Max. Negotiated Rate |
$10,895.24 |
| Rate for Payer: BCBS Complete |
$10,895.24
|
| Rate for Payer: Mclaren Medicaid |
$10,376.42
|
| Rate for Payer: Meridian Medicaid |
$10,895.24
|
| Rate for Payer: Priority Health Choice Medicaid |
$10,376.42
|
| Rate for Payer: UHC Medicaid |
$10,376.42
|
| Rate for Payer: UHCCP Medicaid |
$10,376.42
|
|
|
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC
|
Facility
|
IP
|
$20,014.52
|
|
|
Service Code
|
MSDRG 069
|
| Min. Negotiated Rate |
$6,909.44 |
| Max. Negotiated Rate |
$20,014.52 |
| Rate for Payer: Aetna Medicare |
$7,564.01
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$9,091.36
|
| Rate for Payer: Amish Plain Church Group Commercial |
$9,091.36
|
| Rate for Payer: BCBS MAPPO |
$7,273.09
|
| Rate for Payer: BCBS Trust/PPO |
$20,014.52
|
| Rate for Payer: BCN Commercial |
$20,014.52
|
| Rate for Payer: BCN Medicare Advantage |
$7,273.09
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$7,273.09
|
| Rate for Payer: Mclaren Medicare |
$7,273.09
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$7,636.74
|
| Rate for Payer: MI Amish Medical Board Commercial |
$8,364.05
|
| Rate for Payer: Molina Medicare/Medicaid |
$8,000.40
|
| Rate for Payer: Nomi Health Commercial |
$10,304.52
|
| Rate for Payer: PACE Medicare |
$6,909.44
|
| Rate for Payer: PACE SWMI |
$7,273.09
|
| Rate for Payer: PHP Medicare Advantage |
$7,273.09
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$12,878.37
|
| Rate for Payer: Priority Health Medicare |
$7,273.09
|
| Rate for Payer: Priority Health Tiered Network |
$10,302.69
|
| Rate for Payer: Railroad Medicare Medicare |
$7,273.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$13,020.44
|
| Rate for Payer: UHC Core |
$10,893.24
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$7,273.09
|
| Rate for Payer: UHC Exchange |
$8,896.24
|
| Rate for Payer: VA VA |
$7,273.09
|
|
|
TRANSLUMINAL BALLOON ANGIOPLASTY, CENTRAL DIALYSIS SEGMENT, PERFORMED THROUGH DIALYSIS CIRCUIT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION REQUIRED TO PERFORM THE ANGIOPLASTY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$3,142.85
|
|
|
Service Code
|
CPT 36907
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,142.85 |
| Max. Negotiated Rate |
$3,142.85 |
| Rate for Payer: BCBS Trust/PPO |
$3,142.85
|
| Rate for Payer: BCN Commercial |
$3,142.85
|
|
|
TRANSLUMINAL BALLOON ANGIOPLASTY (EXCEPT DIALYSIS CIRCUIT), OPEN OR PERCUTANEOUS, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY WITHIN THE SAME VEIN; INITIAL VEIN
|
Facility
|
OP
|
$18,339.80
|
|
|
Service Code
|
CPT 37248
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,965.99 |
| Max. Negotiated Rate |
$18,339.80 |
| Rate for Payer: Aetna Medicare |
$5,897.94
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7,088.88
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7,088.88
|
| Rate for Payer: BCBS Complete |
$3,114.57
|
| Rate for Payer: BCBS MAPPO |
$5,671.10
|
| Rate for Payer: BCBS Trust/PPO |
$9,691.75
|
| Rate for Payer: BCN Commercial |
$9,691.75
|
| Rate for Payer: BCN Medicare Advantage |
$5,671.10
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5,671.10
|
| Rate for Payer: Mclaren Medicaid |
$5,671.10
|
| Rate for Payer: Mclaren Medicare |
$5,671.10
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5,954.65
|
| Rate for Payer: Meridian Medicaid |
$5,954.65
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6,521.77
|
| Rate for Payer: Molina Medicare/Medicaid |
$6,238.21
|
| Rate for Payer: Nomi Health Commercial |
$17,013.30
|
| Rate for Payer: PACE Medicare |
$5,387.55
|
| Rate for Payer: PACE SWMI |
$5,671.10
|
| Rate for Payer: PHP Medicare Advantage |
$5,671.10
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,965.99
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$18,339.80
|
| Rate for Payer: Priority Health Medicare |
$5,671.10
|
| Rate for Payer: Priority Health Tiered Network |
$14,671.84
|
| Rate for Payer: Railroad Medicare Medicare |
$5,671.10
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$5,671.10
|
| Rate for Payer: UHC Medicaid |
$2,965.99
|
| Rate for Payer: UHCCP Medicaid |
$2,965.99
|
| Rate for Payer: VA VA |
$5,671.10
|
|
|
TRANSLUMINAL BALLOON ANGIOPLASTY (EXCEPT LOWER EXTREMITY ARTERY(IES) FOR OCCLUSIVE DISEASE, INTRACRANIAL, CORONARY, PULMONARY, OR DIALYSIS CIRCUIT), OPEN OR PERCUTANEOUS, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY WITHIN THE SAME ARTERY; INITIAL ARTERY
|
Facility
|
OP
|
$18,339.80
|
|
|
Service Code
|
CPT 37246
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,965.99 |
| Max. Negotiated Rate |
$18,339.80 |
| Rate for Payer: Aetna Medicare |
$5,897.94
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7,088.88
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7,088.88
|
| Rate for Payer: BCBS Complete |
$3,114.57
|
| Rate for Payer: BCBS MAPPO |
$5,671.10
|
| Rate for Payer: BCBS Trust/PPO |
$6,545.53
|
| Rate for Payer: BCN Commercial |
$6,545.53
|
| Rate for Payer: BCN Medicare Advantage |
$5,671.10
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5,671.10
|
| Rate for Payer: Mclaren Medicaid |
$5,671.10
|
| Rate for Payer: Mclaren Medicare |
$5,671.10
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5,954.65
|
| Rate for Payer: Meridian Medicaid |
$5,954.65
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6,521.77
|
| Rate for Payer: Molina Medicare/Medicaid |
$6,238.21
|
| Rate for Payer: Nomi Health Commercial |
$17,013.30
|
| Rate for Payer: PACE Medicare |
$5,387.55
|
| Rate for Payer: PACE SWMI |
$5,671.10
|
| Rate for Payer: PHP Medicare Advantage |
$5,671.10
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,965.99
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$18,339.80
|
| Rate for Payer: Priority Health Medicare |
$5,671.10
|
| Rate for Payer: Priority Health Tiered Network |
$14,671.84
|
| Rate for Payer: Railroad Medicare Medicare |
$5,671.10
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$5,671.10
|
| Rate for Payer: UHC Medicaid |
$2,965.99
|
| Rate for Payer: UHCCP Medicaid |
$2,965.99
|
| Rate for Payer: VA VA |
$5,671.10
|
|
|
TRANSLUMINAL DILATION OF AQUEOUS OUTFLOW CANAL (EG, CANALOPLASTY); WITHOUT RETENTION OF DEVICE OR STENT
|
Facility
|
OP
|
$13,319.06
|
|
|
Service Code
|
CPT 66174
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,154.01 |
| Max. Negotiated Rate |
$13,319.06 |
| Rate for Payer: Aetna Medicare |
$4,283.30
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$5,148.20
|
| Rate for Payer: Amish Plain Church Group Commercial |
$5,148.20
|
| Rate for Payer: BCBS Complete |
$2,261.91
|
| Rate for Payer: BCBS MAPPO |
$4,118.56
|
| Rate for Payer: BCBS Trust/PPO |
$3,291.01
|
| Rate for Payer: BCN Commercial |
$3,291.01
|
| Rate for Payer: BCN Medicare Advantage |
$4,118.56
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$4,118.56
|
| Rate for Payer: Mclaren Medicaid |
$4,118.56
|
| Rate for Payer: Mclaren Medicare |
$4,118.56
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$4,324.49
|
| Rate for Payer: Meridian Medicaid |
$4,324.49
|
| Rate for Payer: MI Amish Medical Board Commercial |
$4,736.34
|
| Rate for Payer: Molina Medicare/Medicaid |
$4,530.42
|
| Rate for Payer: Nomi Health Commercial |
$12,355.68
|
| Rate for Payer: PACE Medicare |
$3,912.63
|
| Rate for Payer: PACE SWMI |
$4,118.56
|
| Rate for Payer: PHP Medicare Advantage |
$4,118.56
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,154.01
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$13,319.06
|
| Rate for Payer: Priority Health Medicare |
$4,118.56
|
| Rate for Payer: Priority Health Tiered Network |
$10,655.25
|
| Rate for Payer: Railroad Medicare Medicare |
$4,118.56
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$4,118.56
|
| Rate for Payer: UHC Medicaid |
$2,154.01
|
| Rate for Payer: UHCCP Medicaid |
$2,154.01
|
| Rate for Payer: VA VA |
$4,118.56
|
|
|
TRANSURETHRAL DESTRUCTION OF PROSTATE TISSUE; BY RADIOFREQUENCY GENERATED WATER VAPOR THERMOTHERAPY
|
Facility
|
OP
|
$11,358.48
|
|
|
Service Code
|
CPT 53854
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,642.34 |
| Max. Negotiated Rate |
$11,358.48 |
| Rate for Payer: Aetna Medicare |
$3,652.80
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4,390.39
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4,390.39
|
| Rate for Payer: BCBS Complete |
$1,928.96
|
| Rate for Payer: BCBS MAPPO |
$3,512.31
|
| Rate for Payer: BCBS Trust/PPO |
$1,642.34
|
| Rate for Payer: BCN Commercial |
$1,642.34
|
| Rate for Payer: BCN Medicare Advantage |
$3,512.31
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,512.31
|
| Rate for Payer: Mclaren Medicaid |
$3,512.31
|
| Rate for Payer: Mclaren Medicare |
$3,512.31
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,687.93
|
| Rate for Payer: Meridian Medicaid |
$3,687.93
|
| Rate for Payer: MI Amish Medical Board Commercial |
$4,039.16
|
| Rate for Payer: Molina Medicare/Medicaid |
$3,863.54
|
| Rate for Payer: Nomi Health Commercial |
$10,536.93
|
| Rate for Payer: PACE Medicare |
$3,336.69
|
| Rate for Payer: PACE SWMI |
$3,512.31
|
| Rate for Payer: PHP Medicare Advantage |
$3,512.31
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,836.94
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$11,358.48
|
| Rate for Payer: Priority Health Medicare |
$3,512.31
|
| Rate for Payer: Priority Health Tiered Network |
$9,086.78
|
| Rate for Payer: Railroad Medicare Medicare |
$3,512.31
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$3,512.31
|
| Rate for Payer: UHC Medicaid |
$1,836.94
|
| Rate for Payer: UHCCP Medicaid |
$1,836.94
|
| Rate for Payer: VA VA |
$3,512.31
|
|
|
TRANSURETHRAL DRAINAGE OF PROSTATIC ABSCESS
|
Facility
|
OP
|
$11,358.48
|
|
|
Service Code
|
CPT 52700
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,836.94 |
| Max. Negotiated Rate |
$11,358.48 |
| Rate for Payer: Aetna Medicare |
$3,652.80
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4,390.39
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4,390.39
|
| Rate for Payer: BCBS Complete |
$1,928.96
|
| Rate for Payer: BCBS MAPPO |
$3,512.31
|
| Rate for Payer: BCBS Trust/PPO |
$3,274.56
|
| Rate for Payer: BCN Commercial |
$3,274.56
|
| Rate for Payer: BCN Medicare Advantage |
$3,512.31
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,512.31
|
| Rate for Payer: Mclaren Medicaid |
$3,512.31
|
| Rate for Payer: Mclaren Medicare |
$3,512.31
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,687.93
|
| Rate for Payer: Meridian Medicaid |
$3,687.93
|
| Rate for Payer: MI Amish Medical Board Commercial |
$4,039.16
|
| Rate for Payer: Molina Medicare/Medicaid |
$3,863.54
|
| Rate for Payer: Nomi Health Commercial |
$10,536.93
|
| Rate for Payer: PACE Medicare |
$3,336.69
|
| Rate for Payer: PACE SWMI |
$3,512.31
|
| Rate for Payer: PHP Medicare Advantage |
$3,512.31
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,836.94
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$11,358.48
|
| Rate for Payer: Priority Health Medicare |
$3,512.31
|
| Rate for Payer: Priority Health Tiered Network |
$9,086.78
|
| Rate for Payer: Railroad Medicare Medicare |
$3,512.31
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$3,512.31
|
| Rate for Payer: UHC Medicaid |
$1,836.94
|
| Rate for Payer: UHCCP Medicaid |
$1,836.94
|
| Rate for Payer: VA VA |
$3,512.31
|
|
|
TRANSURETHRAL ELECTROSURGICAL RESECTION OF PROSTATE, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED)
|
Facility
|
OP
|
$17,277.20
|
|
|
Service Code
|
CPT 52601
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,794.14 |
| Max. Negotiated Rate |
$17,277.20 |
| Rate for Payer: Aetna Medicare |
$5,556.22
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6,678.15
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6,678.15
|
| Rate for Payer: BCBS Complete |
$2,934.11
|
| Rate for Payer: BCBS MAPPO |
$5,342.52
|
| Rate for Payer: BCBS Trust/PPO |
$4,935.95
|
| Rate for Payer: BCN Commercial |
$4,935.95
|
| Rate for Payer: BCN Medicare Advantage |
$5,342.52
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5,342.52
|
| Rate for Payer: Mclaren Medicaid |
$5,342.52
|
| Rate for Payer: Mclaren Medicare |
$5,342.52
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5,609.65
|
| Rate for Payer: Meridian Medicaid |
$5,609.65
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6,143.90
|
| Rate for Payer: Molina Medicare/Medicaid |
$5,876.77
|
| Rate for Payer: Nomi Health Commercial |
$16,027.56
|
| Rate for Payer: PACE Medicare |
$5,075.39
|
| Rate for Payer: PACE SWMI |
$5,342.52
|
| Rate for Payer: PHP Medicare Advantage |
$5,342.52
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,794.14
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$17,277.20
|
| Rate for Payer: Priority Health Medicare |
$5,342.52
|
| Rate for Payer: Priority Health Tiered Network |
$13,821.76
|
| Rate for Payer: Railroad Medicare Medicare |
$5,342.52
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$5,342.52
|
| Rate for Payer: UHC Medicaid |
$2,794.14
|
| Rate for Payer: UHCCP Medicaid |
$2,794.14
|
| Rate for Payer: VA VA |
$5,342.52
|
|
|
TRANSURETHRAL PROCEDURES WITH CC
|
Facility
|
IP
|
$36,658.07
|
|
|
Service Code
|
MSDRG 669
|
| Min. Negotiated Rate |
$12,893.28 |
| Max. Negotiated Rate |
$36,658.07 |
| Rate for Payer: Aetna Medicare |
$14,114.74
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$16,964.84
|
| Rate for Payer: Amish Plain Church Group Commercial |
$16,964.84
|
| Rate for Payer: BCBS MAPPO |
$13,571.87
|
| Rate for Payer: BCBS Trust/PPO |
$36,658.07
|
| Rate for Payer: BCN Commercial |
$36,658.07
|
| Rate for Payer: BCN Medicare Advantage |
$13,571.87
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$13,571.87
|
| Rate for Payer: Mclaren Medicare |
$13,571.87
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$14,250.46
|
| Rate for Payer: MI Amish Medical Board Commercial |
$15,607.65
|
| Rate for Payer: Molina Medicare/Medicaid |
$14,929.06
|
| Rate for Payer: Nomi Health Commercial |
$20,020.80
|
| Rate for Payer: PACE Medicare |
$12,893.28
|
| Rate for Payer: PACE SWMI |
$13,571.87
|
| Rate for Payer: PHP Medicare Advantage |
$13,571.87
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$25,021.56
|
| Rate for Payer: Priority Health Medicare |
$13,571.87
|
| Rate for Payer: Priority Health Tiered Network |
$20,017.25
|
| Rate for Payer: Railroad Medicare Medicare |
$13,571.87
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$25,297.60
|
| Rate for Payer: UHC Core |
$21,164.62
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$13,571.87
|
| Rate for Payer: UHC Exchange |
$17,284.62
|
| Rate for Payer: VA VA |
$13,571.87
|
|
|
TRANSURETHRAL PROCEDURES WITH MCC
|
Facility
|
IP
|
$51,492.59
|
|
|
Service Code
|
MSDRG 668
|
| Min. Negotiated Rate |
$23,761.43 |
| Max. Negotiated Rate |
$51,492.59 |
| Rate for Payer: Aetna Medicare |
$26,012.51
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$31,265.04
|
| Rate for Payer: Amish Plain Church Group Commercial |
$31,265.04
|
| Rate for Payer: BCBS MAPPO |
$25,012.03
|
| Rate for Payer: BCBS Trust/PPO |
$51,492.59
|
| Rate for Payer: BCN Commercial |
$51,492.59
|
| Rate for Payer: BCN Medicare Advantage |
$25,012.03
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$25,012.03
|
| Rate for Payer: Mclaren Medicare |
$25,012.03
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$26,262.63
|
| Rate for Payer: MI Amish Medical Board Commercial |
$28,763.83
|
| Rate for Payer: Molina Medicare/Medicaid |
$27,513.23
|
| Rate for Payer: Nomi Health Commercial |
$37,668.00
|
| Rate for Payer: PACE Medicare |
$23,761.43
|
| Rate for Payer: PACE SWMI |
$25,012.03
|
| Rate for Payer: PHP Medicare Advantage |
$25,012.03
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$47,076.65
|
| Rate for Payer: Priority Health Medicare |
$25,012.03
|
| Rate for Payer: Priority Health Tiered Network |
$37,661.31
|
| Rate for Payer: Railroad Medicare Medicare |
$25,012.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$47,596.00
|
| Rate for Payer: UHC Core |
$39,820.04
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$25,012.03
|
| Rate for Payer: UHC Exchange |
$32,520.04
|
| Rate for Payer: VA VA |
$25,012.03
|
|
|
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$21,872.96
|
|
|
Service Code
|
MSDRG 670
|
| Min. Negotiated Rate |
$8,327.54 |
| Max. Negotiated Rate |
$21,872.96 |
| Rate for Payer: Aetna Medicare |
$9,116.46
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$10,957.29
|
| Rate for Payer: Amish Plain Church Group Commercial |
$10,957.29
|
| Rate for Payer: BCBS MAPPO |
$8,765.83
|
| Rate for Payer: BCBS Trust/PPO |
$21,872.96
|
| Rate for Payer: BCN Commercial |
$21,872.96
|
| Rate for Payer: BCN Medicare Advantage |
$8,765.83
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$8,765.83
|
| Rate for Payer: Mclaren Medicare |
$8,765.83
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$9,204.12
|
| Rate for Payer: MI Amish Medical Board Commercial |
$10,080.70
|
| Rate for Payer: Molina Medicare/Medicaid |
$9,642.41
|
| Rate for Payer: Nomi Health Commercial |
$12,607.17
|
| Rate for Payer: PACE Medicare |
$8,327.54
|
| Rate for Payer: PACE SWMI |
$8,765.83
|
| Rate for Payer: PHP Medicare Advantage |
$8,765.83
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$15,756.17
|
| Rate for Payer: Priority Health Medicare |
$8,765.83
|
| Rate for Payer: Priority Health Tiered Network |
$12,604.93
|
| Rate for Payer: Railroad Medicare Medicare |
$8,765.83
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$15,929.99
|
| Rate for Payer: UHC Core |
$13,327.44
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$8,765.83
|
| Rate for Payer: UHC Exchange |
$10,884.19
|
| Rate for Payer: VA VA |
$8,765.83
|
|
|
TRANSURETHRAL PROSTATECTOMY
|
Facility
|
IP
|
$5,503.61
|
|
|
Service Code
|
APR-DRG 4821
|
| Min. Negotiated Rate |
$5,241.54 |
| Max. Negotiated Rate |
$5,503.61 |
| Rate for Payer: BCBS Complete |
$5,503.61
|
| Rate for Payer: Mclaren Medicaid |
$5,241.54
|
| Rate for Payer: Meridian Medicaid |
$5,503.61
|
| Rate for Payer: Priority Health Choice Medicaid |
$5,241.54
|
| Rate for Payer: UHC Medicaid |
$5,241.54
|
| Rate for Payer: UHCCP Medicaid |
$5,241.54
|
|
|
TRANSURETHRAL PROSTATECTOMY
|
Facility
|
IP
|
$12,147.06
|
|
|
Service Code
|
APR-DRG 4823
|
| Min. Negotiated Rate |
$11,568.63 |
| Max. Negotiated Rate |
$12,147.06 |
| Rate for Payer: BCBS Complete |
$12,147.06
|
| Rate for Payer: Mclaren Medicaid |
$11,568.63
|
| Rate for Payer: Meridian Medicaid |
$12,147.06
|
| Rate for Payer: Priority Health Choice Medicaid |
$11,568.63
|
| Rate for Payer: UHC Medicaid |
$11,568.63
|
| Rate for Payer: UHCCP Medicaid |
$11,568.63
|
|
