|
HC PED OR PICU ROOM & BOARD
|
Facility
|
IP
|
$5,221.18
|
|
| Hospital Charge Code |
12300001
|
|
Hospital Revenue Code
|
123
|
| Min. Negotiated Rate |
$3,654.83 |
| Max. Negotiated Rate |
$5,221.18 |
| Rate for Payer: Aetna Commercial |
$4,699.06
|
| Rate for Payer: ASR ASR |
$5,064.54
|
| Rate for Payer: BCBS Trust/PPO |
$4,047.98
|
| Rate for Payer: BCN Commercial |
$4,047.98
|
| Rate for Payer: Cash Price |
$4,176.94
|
| Rate for Payer: Cofinity Commercial |
$4,907.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,176.94
|
| Rate for Payer: Healthscope Commercial |
$5,221.18
|
| Rate for Payer: Healthscope Whirlpool |
$5,064.54
|
| Rate for Payer: Mclaren Commercial |
$4,699.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4,438.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,654.83
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4,594.64
|
|
|
HC PED POUCH W/WAFER
|
Facility
|
IP
|
$22.01
|
|
| Hospital Charge Code |
27000133
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$15.41 |
| Max. Negotiated Rate |
$22.01 |
| Rate for Payer: Aetna Commercial |
$19.81
|
| Rate for Payer: ASR ASR |
$21.35
|
| Rate for Payer: BCBS Trust/PPO |
$17.06
|
| Rate for Payer: BCN Commercial |
$17.06
|
| Rate for Payer: Cash Price |
$17.61
|
| Rate for Payer: Cofinity Commercial |
$20.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.61
|
| Rate for Payer: Healthscope Commercial |
$22.01
|
| Rate for Payer: Healthscope Whirlpool |
$21.35
|
| Rate for Payer: Mclaren Commercial |
$19.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$18.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$19.37
|
|
|
HC PED POUCH W/WAFER
|
Facility
|
OP
|
$22.01
|
|
| Hospital Charge Code |
27000133
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$8.80 |
| Max. Negotiated Rate |
$22.01 |
| Rate for Payer: Aetna Commercial |
$19.81
|
| Rate for Payer: ASR ASR |
$21.35
|
| Rate for Payer: BCBS Complete |
$8.80
|
| Rate for Payer: BCBS Trust/PPO |
$17.06
|
| Rate for Payer: BCN Commercial |
$17.06
|
| Rate for Payer: Cash Price |
$17.61
|
| Rate for Payer: Cofinity Commercial |
$20.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.61
|
| Rate for Payer: Healthscope Commercial |
$22.01
|
| Rate for Payer: Healthscope Whirlpool |
$21.35
|
| Rate for Payer: Mclaren Commercial |
$19.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$18.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.41
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$20.03
|
| Rate for Payer: Priority Health Narrow Network |
$15.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$19.37
|
|
|
HC PEDS AUTOIMM ENCEPH CNS, CMPT 1
|
Facility
|
OP
|
$162.05
|
|
|
Service Code
|
CPT 86341
|
| Hospital Charge Code |
30200497
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$12.89 |
| Max. Negotiated Rate |
$162.05 |
| Rate for Payer: Aetna Commercial |
$145.84
|
| Rate for Payer: Aetna Medicare |
$23.57
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$29.46
|
| Rate for Payer: Amish Plain Church Group Commercial |
$29.46
|
| Rate for Payer: ASR ASR |
$157.19
|
| Rate for Payer: BCBS Complete |
$13.54
|
| Rate for Payer: BCBS MAPPO |
$23.57
|
| Rate for Payer: BCBS Trust/PPO |
$125.64
|
| Rate for Payer: BCN Commercial |
$125.64
|
| Rate for Payer: BCN Medicare Advantage |
$23.57
|
| Rate for Payer: Cash Price |
$129.64
|
| Rate for Payer: Cash Price |
$129.64
|
| Rate for Payer: Cofinity Commercial |
$152.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$129.64
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$23.57
|
| Rate for Payer: Healthscope Commercial |
$162.05
|
| Rate for Payer: Healthscope Whirlpool |
$157.19
|
| Rate for Payer: Humana Choice PPO Medicare |
$23.57
|
| Rate for Payer: Mclaren Commercial |
$145.84
|
| Rate for Payer: Mclaren Medicaid |
$12.89
|
| Rate for Payer: Mclaren Medicare |
$23.57
|
| Rate for Payer: Meridian Medicaid |
$13.54
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$24.75
|
| Rate for Payer: MI Amish Medical Board Commercial |
$27.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$137.74
|
| Rate for Payer: PACE Medicare |
$22.39
|
| Rate for Payer: PACE SWMI |
$23.57
|
| Rate for Payer: PHP Commercial |
$25.93
|
| Rate for Payer: PHP Medicaid |
$12.89
|
| Rate for Payer: PHP Medicare Advantage |
$23.57
|
| Rate for Payer: Priority Health Choice Medicaid |
$12.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$113.44
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$147.47
|
| Rate for Payer: Priority Health Medicare |
$23.57
|
| Rate for Payer: Priority Health Narrow Network |
$115.06
|
| Rate for Payer: Railroad Medicare Medicare |
$23.57
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$142.60
|
| Rate for Payer: UHC Medicare Advantage |
$24.28
|
| Rate for Payer: VA VA |
$23.57
|
|
|
HC PEDS AUTOIMM ENCEPH CNS, CMPT 1
|
Facility
|
IP
|
$162.05
|
|
|
Service Code
|
CPT 86341
|
| Hospital Charge Code |
30200497
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$113.44 |
| Max. Negotiated Rate |
$162.05 |
| Rate for Payer: Aetna Commercial |
$145.84
|
| Rate for Payer: ASR ASR |
$157.19
|
| Rate for Payer: BCBS Trust/PPO |
$125.64
|
| Rate for Payer: BCN Commercial |
$125.64
|
| Rate for Payer: Cash Price |
$129.64
|
| Rate for Payer: Cofinity Commercial |
$152.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$129.64
|
| Rate for Payer: Healthscope Commercial |
$162.05
|
| Rate for Payer: Healthscope Whirlpool |
$157.19
|
| Rate for Payer: Mclaren Commercial |
$145.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$137.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$113.44
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$142.60
|
|
|
HC PEDS AUTOIMM ENCEPH CNS, CMPT 2
|
Facility
|
OP
|
$88.34
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
30200498
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$6.59 |
| Max. Negotiated Rate |
$212.42 |
| Rate for Payer: Aetna Commercial |
$79.51
|
| Rate for Payer: Aetna Medicare |
$12.05
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$15.06
|
| Rate for Payer: Amish Plain Church Group Commercial |
$15.06
|
| Rate for Payer: ASR ASR |
$85.69
|
| Rate for Payer: BCBS Complete |
$6.92
|
| Rate for Payer: BCBS MAPPO |
$12.05
|
| Rate for Payer: BCBS Trust/PPO |
$68.49
|
| Rate for Payer: BCN Commercial |
$68.49
|
| Rate for Payer: BCN Medicare Advantage |
$12.05
|
| Rate for Payer: Cash Price |
$70.67
|
| Rate for Payer: Cash Price |
$70.67
|
| Rate for Payer: Cofinity Commercial |
$83.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$70.67
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$12.05
|
| Rate for Payer: Healthscope Commercial |
$88.34
|
| Rate for Payer: Healthscope Whirlpool |
$85.69
|
| Rate for Payer: Humana Choice PPO Medicare |
$12.05
|
| Rate for Payer: Mclaren Commercial |
$79.51
|
| Rate for Payer: Mclaren Medicaid |
$6.59
|
| Rate for Payer: Mclaren Medicare |
$12.05
|
| Rate for Payer: Meridian Medicaid |
$6.92
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$12.65
|
| Rate for Payer: MI Amish Medical Board Commercial |
$13.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$75.09
|
| Rate for Payer: PACE Medicare |
$11.45
|
| Rate for Payer: PACE SWMI |
$12.05
|
| Rate for Payer: PHP Commercial |
$13.26
|
| Rate for Payer: PHP Medicaid |
$6.59
|
| Rate for Payer: PHP Medicare Advantage |
$12.05
|
| Rate for Payer: Priority Health Choice Medicaid |
$6.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$61.84
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$212.42
|
| Rate for Payer: Priority Health Medicare |
$12.05
|
| Rate for Payer: Priority Health Narrow Network |
$169.94
|
| Rate for Payer: Railroad Medicare Medicare |
$12.05
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$77.74
|
| Rate for Payer: UHC Medicare Advantage |
$12.41
|
| Rate for Payer: VA VA |
$12.05
|
|
|
HC PEDS AUTOIMM ENCEPH CNS, CMPT 2
|
Facility
|
IP
|
$88.34
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
30200498
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$61.84 |
| Max. Negotiated Rate |
$88.34 |
| Rate for Payer: Aetna Commercial |
$79.51
|
| Rate for Payer: ASR ASR |
$85.69
|
| Rate for Payer: BCBS Trust/PPO |
$68.49
|
| Rate for Payer: BCN Commercial |
$68.49
|
| Rate for Payer: Cash Price |
$70.67
|
| Rate for Payer: Cofinity Commercial |
$83.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$70.67
|
| Rate for Payer: Healthscope Commercial |
$88.34
|
| Rate for Payer: Healthscope Whirlpool |
$85.69
|
| Rate for Payer: Mclaren Commercial |
$79.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$75.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$61.84
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$77.74
|
|
|
HC PEDS AUTOIMM ENCEPH CNS, CMPT 3
|
Facility
|
OP
|
$263.80
|
|
|
Service Code
|
CPT 86053
|
| Hospital Charge Code |
30200499
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$20.64 |
| Max. Negotiated Rate |
$263.80 |
| Rate for Payer: Aetna Commercial |
$237.42
|
| Rate for Payer: Aetna Medicare |
$37.73
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$47.16
|
| Rate for Payer: Amish Plain Church Group Commercial |
$47.16
|
| Rate for Payer: ASR ASR |
$255.89
|
| Rate for Payer: BCBS Complete |
$21.67
|
| Rate for Payer: BCBS MAPPO |
$37.73
|
| Rate for Payer: BCBS Trust/PPO |
$204.52
|
| Rate for Payer: BCN Commercial |
$204.52
|
| Rate for Payer: BCN Medicare Advantage |
$37.73
|
| Rate for Payer: Cash Price |
$211.04
|
| Rate for Payer: Cash Price |
$211.04
|
| Rate for Payer: Cofinity Commercial |
$247.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$211.04
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$37.73
|
| Rate for Payer: Healthscope Commercial |
$263.80
|
| Rate for Payer: Healthscope Whirlpool |
$255.89
|
| Rate for Payer: Humana Choice PPO Medicare |
$37.73
|
| Rate for Payer: Mclaren Commercial |
$237.42
|
| Rate for Payer: Mclaren Medicaid |
$20.64
|
| Rate for Payer: Mclaren Medicare |
$37.73
|
| Rate for Payer: Meridian Medicaid |
$21.67
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$39.62
|
| Rate for Payer: MI Amish Medical Board Commercial |
$43.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$224.23
|
| Rate for Payer: PACE Medicare |
$35.84
|
| Rate for Payer: PACE SWMI |
$37.73
|
| Rate for Payer: PHP Commercial |
$41.50
|
| Rate for Payer: PHP Medicaid |
$20.64
|
| Rate for Payer: PHP Medicare Advantage |
$37.73
|
| Rate for Payer: Priority Health Choice Medicaid |
$20.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$184.66
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$240.06
|
| Rate for Payer: Priority Health Medicare |
$37.73
|
| Rate for Payer: Priority Health Narrow Network |
$187.30
|
| Rate for Payer: Railroad Medicare Medicare |
$37.73
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$232.14
|
| Rate for Payer: UHC Medicare Advantage |
$38.86
|
| Rate for Payer: VA VA |
$37.73
|
|
|
HC PEDS AUTOIMM ENCEPH CNS, CMPT 3
|
Facility
|
IP
|
$263.80
|
|
|
Service Code
|
CPT 86053
|
| Hospital Charge Code |
30200499
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$184.66 |
| Max. Negotiated Rate |
$263.80 |
| Rate for Payer: Aetna Commercial |
$237.42
|
| Rate for Payer: ASR ASR |
$255.89
|
| Rate for Payer: BCBS Trust/PPO |
$204.52
|
| Rate for Payer: BCN Commercial |
$204.52
|
| Rate for Payer: Cash Price |
$211.04
|
| Rate for Payer: Cofinity Commercial |
$247.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$211.04
|
| Rate for Payer: Healthscope Commercial |
$263.80
|
| Rate for Payer: Healthscope Whirlpool |
$255.89
|
| Rate for Payer: Mclaren Commercial |
$237.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$224.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$184.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$232.14
|
|
|
HC PEDS AUTOIMM ENCEPH CNS, CMPT 4
|
Facility
|
IP
|
$263.80
|
|
|
Service Code
|
CPT 86363
|
| Hospital Charge Code |
30200500
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$184.66 |
| Max. Negotiated Rate |
$263.80 |
| Rate for Payer: Aetna Commercial |
$237.42
|
| Rate for Payer: ASR ASR |
$255.89
|
| Rate for Payer: BCBS Trust/PPO |
$204.52
|
| Rate for Payer: BCN Commercial |
$204.52
|
| Rate for Payer: Cash Price |
$211.04
|
| Rate for Payer: Cofinity Commercial |
$247.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$211.04
|
| Rate for Payer: Healthscope Commercial |
$263.80
|
| Rate for Payer: Healthscope Whirlpool |
$255.89
|
| Rate for Payer: Mclaren Commercial |
$237.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$224.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$184.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$232.14
|
|
|
HC PEDS AUTOIMM ENCEPH CNS, CMPT 4
|
Facility
|
OP
|
$263.80
|
|
|
Service Code
|
CPT 86363
|
| Hospital Charge Code |
30200500
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$20.64 |
| Max. Negotiated Rate |
$263.80 |
| Rate for Payer: Aetna Commercial |
$237.42
|
| Rate for Payer: Aetna Medicare |
$37.73
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$47.16
|
| Rate for Payer: Amish Plain Church Group Commercial |
$47.16
|
| Rate for Payer: ASR ASR |
$255.89
|
| Rate for Payer: BCBS Complete |
$21.67
|
| Rate for Payer: BCBS MAPPO |
$37.73
|
| Rate for Payer: BCBS Trust/PPO |
$204.52
|
| Rate for Payer: BCN Commercial |
$204.52
|
| Rate for Payer: BCN Medicare Advantage |
$37.73
|
| Rate for Payer: Cash Price |
$211.04
|
| Rate for Payer: Cash Price |
$211.04
|
| Rate for Payer: Cofinity Commercial |
$247.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$211.04
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$37.73
|
| Rate for Payer: Healthscope Commercial |
$263.80
|
| Rate for Payer: Healthscope Whirlpool |
$255.89
|
| Rate for Payer: Humana Choice PPO Medicare |
$37.73
|
| Rate for Payer: Mclaren Commercial |
$237.42
|
| Rate for Payer: Mclaren Medicaid |
$20.64
|
| Rate for Payer: Mclaren Medicare |
$37.73
|
| Rate for Payer: Meridian Medicaid |
$21.67
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$39.62
|
| Rate for Payer: MI Amish Medical Board Commercial |
$43.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$224.23
|
| Rate for Payer: PACE Medicare |
$35.84
|
| Rate for Payer: PACE SWMI |
$37.73
|
| Rate for Payer: PHP Commercial |
$41.50
|
| Rate for Payer: PHP Medicaid |
$20.64
|
| Rate for Payer: PHP Medicare Advantage |
$37.73
|
| Rate for Payer: Priority Health Choice Medicaid |
$20.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$184.66
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$240.06
|
| Rate for Payer: Priority Health Medicare |
$37.73
|
| Rate for Payer: Priority Health Narrow Network |
$187.30
|
| Rate for Payer: Railroad Medicare Medicare |
$37.73
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$232.14
|
| Rate for Payer: UHC Medicare Advantage |
$38.86
|
| Rate for Payer: VA VA |
$37.73
|
|
|
HC PEDS ECHO COMPLETE
|
Facility
|
OP
|
$1,969.00
|
|
|
Service Code
|
CPT 93306
|
| Hospital Charge Code |
48300005
|
|
Hospital Revenue Code
|
483
|
| Min. Negotiated Rate |
$268.23 |
| Max. Negotiated Rate |
$1,969.00 |
| Rate for Payer: Aetna Commercial |
$1,772.10
|
| Rate for Payer: Aetna Medicare |
$490.37
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$612.96
|
| Rate for Payer: Amish Plain Church Group Commercial |
$612.96
|
| Rate for Payer: ASR ASR |
$1,909.93
|
| Rate for Payer: BCBS Complete |
$281.67
|
| Rate for Payer: BCBS MAPPO |
$490.37
|
| Rate for Payer: BCBS Trust/PPO |
$1,526.57
|
| Rate for Payer: BCN Commercial |
$1,526.57
|
| Rate for Payer: BCN Medicare Advantage |
$490.37
|
| Rate for Payer: Cash Price |
$1,575.20
|
| Rate for Payer: Cash Price |
$1,575.20
|
| Rate for Payer: Cofinity Commercial |
$1,850.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,575.20
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$490.37
|
| Rate for Payer: Healthscope Commercial |
$1,969.00
|
| Rate for Payer: Healthscope Whirlpool |
$1,909.93
|
| Rate for Payer: Humana Choice PPO Medicare |
$490.37
|
| Rate for Payer: Mclaren Commercial |
$1,772.10
|
| Rate for Payer: Mclaren Medicaid |
$268.23
|
| Rate for Payer: Mclaren Medicare |
$490.37
|
| Rate for Payer: Meridian Medicaid |
$281.67
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$514.89
|
| Rate for Payer: MI Amish Medical Board Commercial |
$563.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,673.65
|
| Rate for Payer: PACE Medicare |
$465.85
|
| Rate for Payer: PACE SWMI |
$490.37
|
| Rate for Payer: PHP Commercial |
$539.41
|
| Rate for Payer: PHP Medicaid |
$268.23
|
| Rate for Payer: PHP Medicare Advantage |
$490.37
|
| Rate for Payer: Priority Health Choice Medicaid |
$268.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,378.30
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,398.68
|
| Rate for Payer: Priority Health Medicare |
$490.37
|
| Rate for Payer: Priority Health Narrow Network |
$1,118.94
|
| Rate for Payer: Railroad Medicare Medicare |
$490.37
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1,732.72
|
| Rate for Payer: UHC Medicare Advantage |
$505.08
|
| Rate for Payer: VA VA |
$490.37
|
|
|
HC PEDS ECHO COMPLETE
|
Facility
|
IP
|
$1,969.00
|
|
|
Service Code
|
CPT 93306
|
| Hospital Charge Code |
48300005
|
|
Hospital Revenue Code
|
483
|
| Min. Negotiated Rate |
$1,378.30 |
| Max. Negotiated Rate |
$1,969.00 |
| Rate for Payer: Aetna Commercial |
$1,772.10
|
| Rate for Payer: ASR ASR |
$1,909.93
|
| Rate for Payer: BCBS Trust/PPO |
$1,526.57
|
| Rate for Payer: BCN Commercial |
$1,526.57
|
| Rate for Payer: Cash Price |
$1,575.20
|
| Rate for Payer: Cofinity Commercial |
$1,850.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,575.20
|
| Rate for Payer: Healthscope Commercial |
$1,969.00
|
| Rate for Payer: Healthscope Whirlpool |
$1,909.93
|
| Rate for Payer: Mclaren Commercial |
$1,772.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,673.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,378.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1,732.72
|
|
|
HC PEDS ECHO LIMITED
|
Facility
|
IP
|
$809.36
|
|
|
Service Code
|
CPT 93308
|
| Hospital Charge Code |
48300006
|
|
Hospital Revenue Code
|
483
|
| Min. Negotiated Rate |
$566.55 |
| Max. Negotiated Rate |
$809.36 |
| Rate for Payer: Aetna Commercial |
$728.42
|
| Rate for Payer: ASR ASR |
$785.08
|
| Rate for Payer: BCBS Trust/PPO |
$627.50
|
| Rate for Payer: BCN Commercial |
$627.50
|
| Rate for Payer: Cash Price |
$647.49
|
| Rate for Payer: Cofinity Commercial |
$760.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$647.49
|
| Rate for Payer: Healthscope Commercial |
$809.36
|
| Rate for Payer: Healthscope Whirlpool |
$785.08
|
| Rate for Payer: Mclaren Commercial |
$728.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$687.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$566.55
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$712.24
|
|
|
HC PEDS ECHO LIMITED
|
Facility
|
OP
|
$809.36
|
|
|
Service Code
|
CPT 93308
|
| Hospital Charge Code |
48300006
|
|
Hospital Revenue Code
|
483
|
| Min. Negotiated Rate |
$119.14 |
| Max. Negotiated Rate |
$809.36 |
| Rate for Payer: Aetna Commercial |
$728.42
|
| Rate for Payer: Aetna Medicare |
$217.81
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$272.26
|
| Rate for Payer: Amish Plain Church Group Commercial |
$272.26
|
| Rate for Payer: ASR ASR |
$785.08
|
| Rate for Payer: BCBS Complete |
$125.11
|
| Rate for Payer: BCBS MAPPO |
$217.81
|
| Rate for Payer: BCBS Trust/PPO |
$627.50
|
| Rate for Payer: BCN Commercial |
$627.50
|
| Rate for Payer: BCN Medicare Advantage |
$217.81
|
| Rate for Payer: Cash Price |
$647.49
|
| Rate for Payer: Cash Price |
$647.49
|
| Rate for Payer: Cofinity Commercial |
$760.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$647.49
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$217.81
|
| Rate for Payer: Healthscope Commercial |
$809.36
|
| Rate for Payer: Healthscope Whirlpool |
$785.08
|
| Rate for Payer: Humana Choice PPO Medicare |
$217.81
|
| Rate for Payer: Mclaren Commercial |
$728.42
|
| Rate for Payer: Mclaren Medicaid |
$119.14
|
| Rate for Payer: Mclaren Medicare |
$217.81
|
| Rate for Payer: Meridian Medicaid |
$125.11
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$228.70
|
| Rate for Payer: MI Amish Medical Board Commercial |
$250.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$687.96
|
| Rate for Payer: PACE Medicare |
$206.92
|
| Rate for Payer: PACE SWMI |
$217.81
|
| Rate for Payer: PHP Commercial |
$239.59
|
| Rate for Payer: PHP Medicaid |
$119.14
|
| Rate for Payer: PHP Medicare Advantage |
$217.81
|
| Rate for Payer: Priority Health Choice Medicaid |
$119.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$566.55
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$510.53
|
| Rate for Payer: Priority Health Medicare |
$217.81
|
| Rate for Payer: Priority Health Narrow Network |
$408.42
|
| Rate for Payer: Railroad Medicare Medicare |
$217.81
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$712.24
|
| Rate for Payer: UHC Medicare Advantage |
$224.34
|
| Rate for Payer: VA VA |
$217.81
|
|
|
HC PEDS ECHO W/DEFINITY
|
Facility
|
OP
|
$1,458.97
|
|
|
Service Code
|
HCPCS C8921
|
| Hospital Charge Code |
48000028
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$389.31 |
| Max. Negotiated Rate |
$1,458.97 |
| Rate for Payer: Aetna Commercial |
$1,313.07
|
| Rate for Payer: Aetna Medicare |
$711.71
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$889.64
|
| Rate for Payer: Amish Plain Church Group Commercial |
$889.64
|
| Rate for Payer: ASR ASR |
$1,415.20
|
| Rate for Payer: BCBS Complete |
$408.81
|
| Rate for Payer: BCBS MAPPO |
$711.71
|
| Rate for Payer: BCBS Trust/PPO |
$1,131.14
|
| Rate for Payer: BCN Commercial |
$1,131.14
|
| Rate for Payer: BCN Medicare Advantage |
$711.71
|
| Rate for Payer: Cash Price |
$1,167.18
|
| Rate for Payer: Cash Price |
$1,167.18
|
| Rate for Payer: Cofinity Commercial |
$1,371.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,167.18
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$711.71
|
| Rate for Payer: Healthscope Commercial |
$1,458.97
|
| Rate for Payer: Healthscope Whirlpool |
$1,415.20
|
| Rate for Payer: Humana Choice PPO Medicare |
$711.71
|
| Rate for Payer: Mclaren Commercial |
$1,313.07
|
| Rate for Payer: Mclaren Medicaid |
$389.31
|
| Rate for Payer: Mclaren Medicare |
$711.71
|
| Rate for Payer: Meridian Medicaid |
$408.81
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$747.30
|
| Rate for Payer: MI Amish Medical Board Commercial |
$818.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,240.12
|
| Rate for Payer: PACE Medicare |
$676.12
|
| Rate for Payer: PACE SWMI |
$711.71
|
| Rate for Payer: PHP Commercial |
$782.88
|
| Rate for Payer: PHP Medicaid |
$389.31
|
| Rate for Payer: PHP Medicare Advantage |
$711.71
|
| Rate for Payer: Priority Health Choice Medicaid |
$389.31
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,021.28
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,327.66
|
| Rate for Payer: Priority Health Medicare |
$711.71
|
| Rate for Payer: Priority Health Narrow Network |
$1,035.87
|
| Rate for Payer: Railroad Medicare Medicare |
$711.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1,283.89
|
| Rate for Payer: UHC Medicare Advantage |
$733.06
|
| Rate for Payer: VA VA |
$711.71
|
|
|
HC PEDS ECHO W/DEFINITY
|
Facility
|
IP
|
$1,458.97
|
|
|
Service Code
|
HCPCS C8921
|
| Hospital Charge Code |
48000028
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$1,021.28 |
| Max. Negotiated Rate |
$1,458.97 |
| Rate for Payer: Aetna Commercial |
$1,313.07
|
| Rate for Payer: ASR ASR |
$1,415.20
|
| Rate for Payer: BCBS Trust/PPO |
$1,131.14
|
| Rate for Payer: BCN Commercial |
$1,131.14
|
| Rate for Payer: Cash Price |
$1,167.18
|
| Rate for Payer: Cofinity Commercial |
$1,371.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,167.18
|
| Rate for Payer: Healthscope Commercial |
$1,458.97
|
| Rate for Payer: Healthscope Whirlpool |
$1,415.20
|
| Rate for Payer: Mclaren Commercial |
$1,313.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,240.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,021.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1,283.89
|
|
|
HC PEDS OBS OVERFLOW PER HR
|
Facility
|
OP
|
$153.31
|
|
| Hospital Charge Code |
76900003
|
|
Hospital Revenue Code
|
769
|
| Min. Negotiated Rate |
$61.32 |
| Max. Negotiated Rate |
$153.31 |
| Rate for Payer: Aetna Commercial |
$137.98
|
| Rate for Payer: ASR ASR |
$148.71
|
| Rate for Payer: BCBS Complete |
$61.32
|
| Rate for Payer: BCBS Trust/PPO |
$118.86
|
| Rate for Payer: BCN Commercial |
$118.86
|
| Rate for Payer: Cash Price |
$122.65
|
| Rate for Payer: Cofinity Commercial |
$144.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$122.65
|
| Rate for Payer: Healthscope Commercial |
$153.31
|
| Rate for Payer: Healthscope Whirlpool |
$148.71
|
| Rate for Payer: Mclaren Commercial |
$137.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$130.31
|
| Rate for Payer: Priority Health Cigna Priority Health |
$107.32
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$139.51
|
| Rate for Payer: Priority Health Narrow Network |
$108.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$134.91
|
|
|
HC PEDS OBS OVERFLOW PER HR
|
Facility
|
IP
|
$153.31
|
|
| Hospital Charge Code |
76900003
|
|
Hospital Revenue Code
|
769
|
| Min. Negotiated Rate |
$107.32 |
| Max. Negotiated Rate |
$153.31 |
| Rate for Payer: Aetna Commercial |
$137.98
|
| Rate for Payer: ASR ASR |
$148.71
|
| Rate for Payer: BCBS Trust/PPO |
$118.86
|
| Rate for Payer: BCN Commercial |
$118.86
|
| Rate for Payer: Cash Price |
$122.65
|
| Rate for Payer: Cofinity Commercial |
$144.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$122.65
|
| Rate for Payer: Healthscope Commercial |
$153.31
|
| Rate for Payer: Healthscope Whirlpool |
$148.71
|
| Rate for Payer: Mclaren Commercial |
$137.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$130.31
|
| Rate for Payer: Priority Health Cigna Priority Health |
$107.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$134.91
|
|
|
HC PEDS VENT INIT DAY
|
Facility
|
IP
|
$1,491.66
|
|
|
Service Code
|
CPT 94002
|
| Hospital Charge Code |
41000035
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$1,044.16 |
| Max. Negotiated Rate |
$1,491.66 |
| Rate for Payer: Aetna Commercial |
$1,342.49
|
| Rate for Payer: ASR ASR |
$1,446.91
|
| Rate for Payer: BCBS Trust/PPO |
$1,156.48
|
| Rate for Payer: BCN Commercial |
$1,156.48
|
| Rate for Payer: Cash Price |
$1,193.33
|
| Rate for Payer: Cofinity Commercial |
$1,402.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,193.33
|
| Rate for Payer: Healthscope Commercial |
$1,491.66
|
| Rate for Payer: Healthscope Whirlpool |
$1,446.91
|
| Rate for Payer: Mclaren Commercial |
$1,342.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,267.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,044.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1,312.66
|
|
|
HC PEDS VENT INIT DAY
|
Facility
|
OP
|
$1,491.66
|
|
|
Service Code
|
CPT 94002
|
| Hospital Charge Code |
41000035
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$304.70 |
| Max. Negotiated Rate |
$3,776.34 |
| Rate for Payer: Aetna Commercial |
$1,342.49
|
| Rate for Payer: Aetna Medicare |
$557.03
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$696.29
|
| Rate for Payer: Amish Plain Church Group Commercial |
$696.29
|
| Rate for Payer: ASR ASR |
$1,446.91
|
| Rate for Payer: BCBS Complete |
$319.96
|
| Rate for Payer: BCBS MAPPO |
$557.03
|
| Rate for Payer: BCBS Trust/PPO |
$1,156.48
|
| Rate for Payer: BCN Commercial |
$1,156.48
|
| Rate for Payer: BCN Medicare Advantage |
$557.03
|
| Rate for Payer: Cash Price |
$1,193.33
|
| Rate for Payer: Cash Price |
$1,193.33
|
| Rate for Payer: Cofinity Commercial |
$1,402.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,193.33
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$557.03
|
| Rate for Payer: Healthscope Commercial |
$1,491.66
|
| Rate for Payer: Healthscope Whirlpool |
$1,446.91
|
| Rate for Payer: Humana Choice PPO Medicare |
$557.03
|
| Rate for Payer: Mclaren Commercial |
$1,342.49
|
| Rate for Payer: Mclaren Medicaid |
$304.70
|
| Rate for Payer: Mclaren Medicare |
$557.03
|
| Rate for Payer: Meridian Medicaid |
$319.96
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$584.88
|
| Rate for Payer: MI Amish Medical Board Commercial |
$640.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,267.91
|
| Rate for Payer: PACE Medicare |
$529.18
|
| Rate for Payer: PACE SWMI |
$557.03
|
| Rate for Payer: PHP Commercial |
$612.73
|
| Rate for Payer: PHP Medicaid |
$304.70
|
| Rate for Payer: PHP Medicare Advantage |
$557.03
|
| Rate for Payer: Priority Health Choice Medicaid |
$304.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,044.16
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$3,776.34
|
| Rate for Payer: Priority Health Medicare |
$557.03
|
| Rate for Payer: Priority Health Narrow Network |
$3,021.07
|
| Rate for Payer: Railroad Medicare Medicare |
$557.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1,312.66
|
| Rate for Payer: UHC Medicare Advantage |
$573.74
|
| Rate for Payer: VA VA |
$557.03
|
|
|
HC PEDS VENT SUB DAY
|
Facility
|
OP
|
$1,289.42
|
|
|
Service Code
|
CPT 94003
|
| Hospital Charge Code |
41000036
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$304.70 |
| Max. Negotiated Rate |
$3,304.30 |
| Rate for Payer: Aetna Commercial |
$1,160.48
|
| Rate for Payer: Aetna Medicare |
$557.03
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$696.29
|
| Rate for Payer: Amish Plain Church Group Commercial |
$696.29
|
| Rate for Payer: ASR ASR |
$1,250.74
|
| Rate for Payer: BCBS Complete |
$319.96
|
| Rate for Payer: BCBS MAPPO |
$557.03
|
| Rate for Payer: BCBS Trust/PPO |
$999.69
|
| Rate for Payer: BCN Commercial |
$999.69
|
| Rate for Payer: BCN Medicare Advantage |
$557.03
|
| Rate for Payer: Cash Price |
$1,031.54
|
| Rate for Payer: Cash Price |
$1,031.54
|
| Rate for Payer: Cofinity Commercial |
$1,212.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,031.54
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$557.03
|
| Rate for Payer: Healthscope Commercial |
$1,289.42
|
| Rate for Payer: Healthscope Whirlpool |
$1,250.74
|
| Rate for Payer: Humana Choice PPO Medicare |
$557.03
|
| Rate for Payer: Mclaren Commercial |
$1,160.48
|
| Rate for Payer: Mclaren Medicaid |
$304.70
|
| Rate for Payer: Mclaren Medicare |
$557.03
|
| Rate for Payer: Meridian Medicaid |
$319.96
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$584.88
|
| Rate for Payer: MI Amish Medical Board Commercial |
$640.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,096.01
|
| Rate for Payer: PACE Medicare |
$529.18
|
| Rate for Payer: PACE SWMI |
$557.03
|
| Rate for Payer: PHP Commercial |
$612.73
|
| Rate for Payer: PHP Medicaid |
$304.70
|
| Rate for Payer: PHP Medicare Advantage |
$557.03
|
| Rate for Payer: Priority Health Choice Medicaid |
$304.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$902.59
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$3,304.30
|
| Rate for Payer: Priority Health Medicare |
$557.03
|
| Rate for Payer: Priority Health Narrow Network |
$2,643.44
|
| Rate for Payer: Railroad Medicare Medicare |
$557.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1,134.69
|
| Rate for Payer: UHC Medicare Advantage |
$573.74
|
| Rate for Payer: VA VA |
$557.03
|
|
|
HC PEDS VENT SUB DAY
|
Facility
|
IP
|
$1,289.42
|
|
|
Service Code
|
CPT 94003
|
| Hospital Charge Code |
41000036
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$902.59 |
| Max. Negotiated Rate |
$1,289.42 |
| Rate for Payer: Aetna Commercial |
$1,160.48
|
| Rate for Payer: ASR ASR |
$1,250.74
|
| Rate for Payer: BCBS Trust/PPO |
$999.69
|
| Rate for Payer: BCN Commercial |
$999.69
|
| Rate for Payer: Cash Price |
$1,031.54
|
| Rate for Payer: Cofinity Commercial |
$1,212.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,031.54
|
| Rate for Payer: Healthscope Commercial |
$1,289.42
|
| Rate for Payer: Healthscope Whirlpool |
$1,250.74
|
| Rate for Payer: Mclaren Commercial |
$1,160.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,096.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$902.59
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1,134.69
|
|
|
HC PEG TUBE INSERTION/TRAY
|
Facility
|
IP
|
$1,187.11
|
|
| Hospital Charge Code |
36000079
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$830.98 |
| Max. Negotiated Rate |
$1,187.11 |
| Rate for Payer: Aetna Commercial |
$1,068.40
|
| Rate for Payer: ASR ASR |
$1,151.50
|
| Rate for Payer: BCBS Trust/PPO |
$920.37
|
| Rate for Payer: BCN Commercial |
$920.37
|
| Rate for Payer: Cash Price |
$949.69
|
| Rate for Payer: Cofinity Commercial |
$1,115.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$949.69
|
| Rate for Payer: Healthscope Commercial |
$1,187.11
|
| Rate for Payer: Healthscope Whirlpool |
$1,151.50
|
| Rate for Payer: Mclaren Commercial |
$1,068.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,009.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$830.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1,044.66
|
|
|
HC PEG TUBE INSERTION/TRAY
|
Facility
|
OP
|
$1,187.11
|
|
| Hospital Charge Code |
36000079
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$474.84 |
| Max. Negotiated Rate |
$1,187.11 |
| Rate for Payer: Aetna Commercial |
$1,068.40
|
| Rate for Payer: ASR ASR |
$1,151.50
|
| Rate for Payer: BCBS Complete |
$474.84
|
| Rate for Payer: BCBS Trust/PPO |
$920.37
|
| Rate for Payer: BCN Commercial |
$920.37
|
| Rate for Payer: Cash Price |
$949.69
|
| Rate for Payer: Cofinity Commercial |
$1,115.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$949.69
|
| Rate for Payer: Healthscope Commercial |
$1,187.11
|
| Rate for Payer: Healthscope Whirlpool |
$1,151.50
|
| Rate for Payer: Mclaren Commercial |
$1,068.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,009.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$830.98
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,080.27
|
| Rate for Payer: Priority Health Narrow Network |
$842.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1,044.66
|
|
