|
PR EXC LESION TDN SHTH/JT CAPSL HAND/FNGR
|
Professional
|
Both
|
$1,035.00
|
|
|
Service Code
|
HCPCS 26160
|
| Hospital Charge Code |
26160
|
| Min. Negotiated Rate |
$78.72 |
| Max. Negotiated Rate |
$912.85 |
| Rate for Payer: Aetna Commercial |
$416.91
|
| Rate for Payer: Aetna Medicare |
$311.13
|
| Rate for Payer: BCBS Complete |
$217.83
|
| Rate for Payer: BCBS MAPPO |
$311.13
|
| Rate for Payer: BCBS Trust/PPO |
$78.72
|
| Rate for Payer: BCN Commercial |
$912.85
|
| Rate for Payer: BCN Medicare Advantage |
$311.13
|
| Rate for Payer: Cash Price |
$828.00
|
| Rate for Payer: Cash Price |
$828.00
|
| Rate for Payer: Cofinity Commercial |
$448.03
|
| Rate for Payer: Cofinity Commercial |
$416.91
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$311.13
|
| Rate for Payer: Healthscope Commercial |
$373.36
|
| Rate for Payer: Healthscope Whirlpool |
$373.36
|
| Rate for Payer: Meridian Medicaid |
$217.83
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$326.69
|
| Rate for Payer: PACE SWMI |
$311.13
|
| Rate for Payer: PHP Medicare Advantage |
$311.13
|
| Rate for Payer: Priority Health Choice Medicaid |
$207.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$724.50
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$490.74
|
| Rate for Payer: Priority Health Medicare |
$311.13
|
| Rate for Payer: Priority Health Narrow Network |
$490.74
|
| Rate for Payer: UHC Medicare Advantage |
$320.46
|
|
|
PR EXC LESION TDN SHTH/JT CAPSL HAND/FNGR
|
Facility
|
OP
|
$1,035.00
|
|
|
Service Code
|
CPT 26160
|
| Hospital Charge Code |
26160
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$724.50 |
| Max. Negotiated Rate |
$1,785.76 |
| Rate for Payer: Aetna Commercial |
$931.50
|
| Rate for Payer: Aetna Medicare |
$1,428.61
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1,785.76
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1,785.76
|
| Rate for Payer: ASR ASR |
$1,003.95
|
| Rate for Payer: BCBS Complete |
$820.59
|
| Rate for Payer: BCBS MAPPO |
$1,428.61
|
| Rate for Payer: BCBS Trust/PPO |
$802.44
|
| Rate for Payer: BCN Commercial |
$802.44
|
| Rate for Payer: BCN Medicare Advantage |
$1,428.61
|
| Rate for Payer: Cash Price |
$828.00
|
| Rate for Payer: Cash Price |
$828.00
|
| Rate for Payer: Cofinity Commercial |
$972.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$828.00
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,428.61
|
| Rate for Payer: Healthscope Commercial |
$1,035.00
|
| Rate for Payer: Healthscope Whirlpool |
$1,003.95
|
| Rate for Payer: Humana Choice PPO Medicare |
$1,428.61
|
| Rate for Payer: Mclaren Commercial |
$931.50
|
| Rate for Payer: Mclaren Medicaid |
$781.45
|
| Rate for Payer: Mclaren Medicare |
$1,428.61
|
| Rate for Payer: Meridian Medicaid |
$820.59
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$1,500.04
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,642.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$879.75
|
| Rate for Payer: PACE Medicare |
$1,357.18
|
| Rate for Payer: PACE SWMI |
$1,428.61
|
| Rate for Payer: PHP Commercial |
$1,571.47
|
| Rate for Payer: PHP Medicaid |
$781.45
|
| Rate for Payer: PHP Medicare Advantage |
$1,428.61
|
| Rate for Payer: Priority Health Choice Medicaid |
$781.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$724.50
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$941.85
|
| Rate for Payer: Priority Health Medicare |
$1,428.61
|
| Rate for Payer: Priority Health Narrow Network |
$734.85
|
| Rate for Payer: Railroad Medicare Medicare |
$1,428.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$910.80
|
| Rate for Payer: UHC Medicare Advantage |
$1,471.47
|
| Rate for Payer: VA VA |
$1,428.61
|
|
|
PR EXC LESION TDN SHTH/JT CAPSL HAND/FNGR
|
Facility
|
IP
|
$1,035.00
|
|
|
Service Code
|
CPT 26160
|
| Hospital Charge Code |
26160
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$724.50 |
| Max. Negotiated Rate |
$1,035.00 |
| Rate for Payer: Aetna Commercial |
$931.50
|
| Rate for Payer: ASR ASR |
$1,003.95
|
| Rate for Payer: BCBS Trust/PPO |
$802.44
|
| Rate for Payer: BCN Commercial |
$802.44
|
| Rate for Payer: Cash Price |
$828.00
|
| Rate for Payer: Cofinity Commercial |
$972.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$828.00
|
| Rate for Payer: Healthscope Commercial |
$1,035.00
|
| Rate for Payer: Healthscope Whirlpool |
$1,003.95
|
| Rate for Payer: Mclaren Commercial |
$931.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$879.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$724.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$910.80
|
|
|
PR EXC LESION TENDON SHEATH/CAPSULE W/SYNVCT FOOT
|
Facility
|
OP
|
$869.00
|
|
|
Service Code
|
CPT 28090
|
| Hospital Charge Code |
28090
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$608.30 |
| Max. Negotiated Rate |
$1,785.76 |
| Rate for Payer: Aetna Commercial |
$782.10
|
| Rate for Payer: Aetna Medicare |
$1,428.61
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1,785.76
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1,785.76
|
| Rate for Payer: ASR ASR |
$842.93
|
| Rate for Payer: BCBS Complete |
$820.59
|
| Rate for Payer: BCBS MAPPO |
$1,428.61
|
| Rate for Payer: BCBS Trust/PPO |
$673.74
|
| Rate for Payer: BCN Commercial |
$673.74
|
| Rate for Payer: BCN Medicare Advantage |
$1,428.61
|
| Rate for Payer: Cash Price |
$695.20
|
| Rate for Payer: Cash Price |
$695.20
|
| Rate for Payer: Cofinity Commercial |
$816.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$695.20
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,428.61
|
| Rate for Payer: Healthscope Commercial |
$869.00
|
| Rate for Payer: Healthscope Whirlpool |
$842.93
|
| Rate for Payer: Humana Choice PPO Medicare |
$1,428.61
|
| Rate for Payer: Mclaren Commercial |
$782.10
|
| Rate for Payer: Mclaren Medicaid |
$781.45
|
| Rate for Payer: Mclaren Medicare |
$1,428.61
|
| Rate for Payer: Meridian Medicaid |
$820.59
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$1,500.04
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,642.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$738.65
|
| Rate for Payer: PACE Medicare |
$1,357.18
|
| Rate for Payer: PACE SWMI |
$1,428.61
|
| Rate for Payer: PHP Commercial |
$1,571.47
|
| Rate for Payer: PHP Medicaid |
$781.45
|
| Rate for Payer: PHP Medicare Advantage |
$1,428.61
|
| Rate for Payer: Priority Health Choice Medicaid |
$781.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$608.30
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$790.79
|
| Rate for Payer: Priority Health Medicare |
$1,428.61
|
| Rate for Payer: Priority Health Narrow Network |
$616.99
|
| Rate for Payer: Railroad Medicare Medicare |
$1,428.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$764.72
|
| Rate for Payer: UHC Medicare Advantage |
$1,471.47
|
| Rate for Payer: VA VA |
$1,428.61
|
|
|
PR EXC LESION TENDON SHEATH/CAPSULE W/SYNVCT FOOT
|
Professional
|
Both
|
$869.00
|
|
|
Service Code
|
HCPCS 28090
|
| Min. Negotiated Rate |
$199.37 |
| Max. Negotiated Rate |
$676.82 |
| Rate for Payer: Aetna Commercial |
$402.42
|
| Rate for Payer: Aetna Medicare |
$300.31
|
| Rate for Payer: BCBS Complete |
$209.34
|
| Rate for Payer: BCBS MAPPO |
$300.31
|
| Rate for Payer: BCBS Trust/PPO |
$404.15
|
| Rate for Payer: BCN Commercial |
$676.82
|
| Rate for Payer: BCN Medicare Advantage |
$300.31
|
| Rate for Payer: Cash Price |
$695.20
|
| Rate for Payer: Cash Price |
$695.20
|
| Rate for Payer: Cofinity Commercial |
$402.42
|
| Rate for Payer: Cofinity Commercial |
$432.45
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$300.31
|
| Rate for Payer: Healthscope Commercial |
$360.37
|
| Rate for Payer: Healthscope Whirlpool |
$360.37
|
| Rate for Payer: Meridian Medicaid |
$209.34
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$315.33
|
| Rate for Payer: PACE SWMI |
$300.31
|
| Rate for Payer: PHP Medicare Advantage |
$300.31
|
| Rate for Payer: Priority Health Choice Medicaid |
$199.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$608.30
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$469.79
|
| Rate for Payer: Priority Health Medicare |
$300.31
|
| Rate for Payer: Priority Health Narrow Network |
$469.79
|
| Rate for Payer: UHC Medicare Advantage |
$309.32
|
|
|
PR EXC LESION TENDON SHEATH/CAPSULE W/SYNVCT FOOT
|
Professional
|
Both
|
$869.00
|
|
|
Service Code
|
HCPCS 28090
|
| Hospital Charge Code |
28090
|
| Min. Negotiated Rate |
$199.37 |
| Max. Negotiated Rate |
$676.82 |
| Rate for Payer: Aetna Commercial |
$402.42
|
| Rate for Payer: Aetna Medicare |
$300.31
|
| Rate for Payer: BCBS Complete |
$209.34
|
| Rate for Payer: BCBS MAPPO |
$300.31
|
| Rate for Payer: BCBS Trust/PPO |
$404.15
|
| Rate for Payer: BCN Commercial |
$676.82
|
| Rate for Payer: BCN Medicare Advantage |
$300.31
|
| Rate for Payer: Cash Price |
$695.20
|
| Rate for Payer: Cash Price |
$695.20
|
| Rate for Payer: Cofinity Commercial |
$432.45
|
| Rate for Payer: Cofinity Commercial |
$402.42
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$300.31
|
| Rate for Payer: Healthscope Commercial |
$360.37
|
| Rate for Payer: Healthscope Whirlpool |
$360.37
|
| Rate for Payer: Meridian Medicaid |
$209.34
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$315.33
|
| Rate for Payer: PACE SWMI |
$300.31
|
| Rate for Payer: PHP Medicare Advantage |
$300.31
|
| Rate for Payer: Priority Health Choice Medicaid |
$199.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$608.30
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$469.79
|
| Rate for Payer: Priority Health Medicare |
$300.31
|
| Rate for Payer: Priority Health Narrow Network |
$469.79
|
| Rate for Payer: UHC Medicare Advantage |
$309.32
|
|
|
PR EXC LESION TENDON SHEATH/CAPSULE W/SYNVCT FOOT
|
Facility
|
IP
|
$869.00
|
|
|
Service Code
|
CPT 28090
|
| Hospital Charge Code |
28090
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$608.30 |
| Max. Negotiated Rate |
$869.00 |
| Rate for Payer: Aetna Commercial |
$782.10
|
| Rate for Payer: ASR ASR |
$842.93
|
| Rate for Payer: BCBS Trust/PPO |
$673.74
|
| Rate for Payer: BCN Commercial |
$673.74
|
| Rate for Payer: Cash Price |
$695.20
|
| Rate for Payer: Cofinity Commercial |
$816.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$695.20
|
| Rate for Payer: Healthscope Commercial |
$869.00
|
| Rate for Payer: Healthscope Whirlpool |
$842.93
|
| Rate for Payer: Mclaren Commercial |
$782.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$738.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$608.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$764.72
|
|
|
PR EXC LESION TENDON SHEATH/CAPSULE W/SYNVCT TOE EA
|
Professional
|
Both
|
$813.00
|
|
|
Service Code
|
HCPCS 28092
|
| Min. Negotiated Rate |
$176.36 |
| Max. Negotiated Rate |
$612.80 |
| Rate for Payer: Aetna Commercial |
$352.71
|
| Rate for Payer: Aetna Medicare |
$263.22
|
| Rate for Payer: BCBS Complete |
$185.18
|
| Rate for Payer: BCBS MAPPO |
$263.22
|
| Rate for Payer: BCBS Trust/PPO |
$353.43
|
| Rate for Payer: BCN Commercial |
$612.80
|
| Rate for Payer: BCN Medicare Advantage |
$263.22
|
| Rate for Payer: Cash Price |
$650.40
|
| Rate for Payer: Cash Price |
$650.40
|
| Rate for Payer: Cofinity Commercial |
$379.04
|
| Rate for Payer: Cofinity Commercial |
$352.71
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$263.22
|
| Rate for Payer: Healthscope Commercial |
$315.86
|
| Rate for Payer: Healthscope Whirlpool |
$315.86
|
| Rate for Payer: Meridian Medicaid |
$185.18
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$276.38
|
| Rate for Payer: PACE SWMI |
$263.22
|
| Rate for Payer: PHP Medicare Advantage |
$263.22
|
| Rate for Payer: Priority Health Choice Medicaid |
$176.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$569.10
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$413.12
|
| Rate for Payer: Priority Health Medicare |
$263.22
|
| Rate for Payer: Priority Health Narrow Network |
$413.12
|
| Rate for Payer: UHC Medicare Advantage |
$271.12
|
|
|
PR EXC LESION TONGUE W/CLSR ANTERIOR TWO-THIRDS
|
Professional
|
Both
|
$581.00
|
|
|
Service Code
|
HCPCS 41112
|
| Min. Negotiated Rate |
$156.13 |
| Max. Negotiated Rate |
$534.11 |
| Rate for Payer: Aetna Commercial |
$316.04
|
| Rate for Payer: Aetna Medicare |
$235.85
|
| Rate for Payer: BCBS Complete |
$163.94
|
| Rate for Payer: BCBS MAPPO |
$235.85
|
| Rate for Payer: BCBS Trust/PPO |
$534.11
|
| Rate for Payer: BCN Commercial |
$499.92
|
| Rate for Payer: BCN Medicare Advantage |
$235.85
|
| Rate for Payer: Cash Price |
$464.80
|
| Rate for Payer: Cash Price |
$464.80
|
| Rate for Payer: Cofinity Commercial |
$339.62
|
| Rate for Payer: Cofinity Commercial |
$316.04
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$235.85
|
| Rate for Payer: Healthscope Commercial |
$283.02
|
| Rate for Payer: Healthscope Whirlpool |
$283.02
|
| Rate for Payer: Meridian Medicaid |
$163.94
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$247.64
|
| Rate for Payer: PACE SWMI |
$235.85
|
| Rate for Payer: PHP Medicare Advantage |
$235.85
|
| Rate for Payer: Priority Health Choice Medicaid |
$156.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$406.70
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$429.23
|
| Rate for Payer: Priority Health Medicare |
$235.85
|
| Rate for Payer: Priority Health Narrow Network |
$429.23
|
| Rate for Payer: UHC Medicare Advantage |
$242.93
|
|
|
PR EXC LESION TONGUE W/CLSR POSTERIOR ONE-THIRD
|
Professional
|
Both
|
$742.00
|
|
|
Service Code
|
HCPCS 41113
|
| Min. Negotiated Rate |
$169.34 |
| Max. Negotiated Rate |
$569.51 |
| Rate for Payer: Aetna Commercial |
$345.01
|
| Rate for Payer: Aetna Medicare |
$257.47
|
| Rate for Payer: BCBS Complete |
$177.81
|
| Rate for Payer: BCBS MAPPO |
$257.47
|
| Rate for Payer: BCBS Trust/PPO |
$569.51
|
| Rate for Payer: BCN Commercial |
$535.59
|
| Rate for Payer: BCN Medicare Advantage |
$257.47
|
| Rate for Payer: Cash Price |
$593.60
|
| Rate for Payer: Cash Price |
$593.60
|
| Rate for Payer: Cofinity Commercial |
$370.76
|
| Rate for Payer: Cofinity Commercial |
$345.01
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$257.47
|
| Rate for Payer: Healthscope Commercial |
$308.96
|
| Rate for Payer: Healthscope Whirlpool |
$308.96
|
| Rate for Payer: Meridian Medicaid |
$177.81
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$270.34
|
| Rate for Payer: PACE SWMI |
$257.47
|
| Rate for Payer: PHP Medicare Advantage |
$257.47
|
| Rate for Payer: Priority Health Choice Medicaid |
$169.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$519.40
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$467.43
|
| Rate for Payer: Priority Health Medicare |
$257.47
|
| Rate for Payer: Priority Health Narrow Network |
$467.43
|
| Rate for Payer: UHC Medicare Advantage |
$265.19
|
|
|
PR EXC LESION TONGUE W/CLSR W/LOCAL TONGUE FLAP
|
Professional
|
Both
|
$1,132.00
|
|
|
Service Code
|
HCPCS 41114
|
| Min. Negotiated Rate |
$398.95 |
| Max. Negotiated Rate |
$1,097.17 |
| Rate for Payer: Aetna Commercial |
$817.00
|
| Rate for Payer: Aetna Medicare |
$609.70
|
| Rate for Payer: BCBS Complete |
$418.90
|
| Rate for Payer: BCBS MAPPO |
$609.70
|
| Rate for Payer: BCBS Trust/PPO |
$515.09
|
| Rate for Payer: BCN Commercial |
$911.87
|
| Rate for Payer: BCN Medicare Advantage |
$609.70
|
| Rate for Payer: Cash Price |
$905.60
|
| Rate for Payer: Cash Price |
$905.60
|
| Rate for Payer: Cofinity Commercial |
$877.97
|
| Rate for Payer: Cofinity Commercial |
$817.00
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$609.70
|
| Rate for Payer: Healthscope Commercial |
$731.64
|
| Rate for Payer: Healthscope Whirlpool |
$731.64
|
| Rate for Payer: Meridian Medicaid |
$418.90
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$640.18
|
| Rate for Payer: PACE SWMI |
$609.70
|
| Rate for Payer: PHP Medicare Advantage |
$609.70
|
| Rate for Payer: Priority Health Choice Medicaid |
$398.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$792.40
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,097.17
|
| Rate for Payer: Priority Health Medicare |
$609.70
|
| Rate for Payer: Priority Health Narrow Network |
$1,097.17
|
| Rate for Payer: UHC Medicare Advantage |
$627.99
|
|
|
PR EXC LESION/TUMOR DENTALVEOLAR STRUX W/CMPLX RPR
|
Professional
|
Both
|
$697.00
|
|
|
Service Code
|
HCPCS 41827
|
| Min. Negotiated Rate |
$184.88 |
| Max. Negotiated Rate |
$633.33 |
| Rate for Payer: Aetna Commercial |
$373.97
|
| Rate for Payer: Aetna Medicare |
$279.08
|
| Rate for Payer: BCBS Complete |
$194.12
|
| Rate for Payer: BCBS MAPPO |
$279.08
|
| Rate for Payer: BCBS Trust/PPO |
$529.88
|
| Rate for Payer: BCN Commercial |
$633.33
|
| Rate for Payer: BCN Medicare Advantage |
$279.08
|
| Rate for Payer: Cash Price |
$557.60
|
| Rate for Payer: Cash Price |
$557.60
|
| Rate for Payer: Cofinity Commercial |
$401.88
|
| Rate for Payer: Cofinity Commercial |
$373.97
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$279.08
|
| Rate for Payer: Healthscope Commercial |
$334.90
|
| Rate for Payer: Healthscope Whirlpool |
$334.90
|
| Rate for Payer: Meridian Medicaid |
$194.12
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$293.03
|
| Rate for Payer: PACE SWMI |
$279.08
|
| Rate for Payer: PHP Medicare Advantage |
$279.08
|
| Rate for Payer: Priority Health Choice Medicaid |
$184.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$487.90
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$505.07
|
| Rate for Payer: Priority Health Medicare |
$279.08
|
| Rate for Payer: Priority Health Narrow Network |
$505.07
|
| Rate for Payer: UHC Medicare Advantage |
$287.45
|
|
|
PR EXC LESION/TUMOR DENTOALVEOLAR STRUX W/O RPR
|
Professional
|
Both
|
$412.00
|
|
|
Service Code
|
HCPCS 41825
|
| Min. Negotiated Rate |
$78.17 |
| Max. Negotiated Rate |
$339.70 |
| Rate for Payer: Aetna Commercial |
$157.14
|
| Rate for Payer: Aetna Medicare |
$117.27
|
| Rate for Payer: BCBS Complete |
$82.08
|
| Rate for Payer: BCBS MAPPO |
$117.27
|
| Rate for Payer: BCBS Trust/PPO |
$339.70
|
| Rate for Payer: BCN Commercial |
$324.97
|
| Rate for Payer: BCN Medicare Advantage |
$117.27
|
| Rate for Payer: Cash Price |
$329.60
|
| Rate for Payer: Cash Price |
$329.60
|
| Rate for Payer: Cofinity Commercial |
$157.14
|
| Rate for Payer: Cofinity Commercial |
$168.87
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$117.27
|
| Rate for Payer: Healthscope Commercial |
$140.72
|
| Rate for Payer: Healthscope Whirlpool |
$140.72
|
| Rate for Payer: Meridian Medicaid |
$82.08
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$123.13
|
| Rate for Payer: PACE SWMI |
$117.27
|
| Rate for Payer: PHP Medicare Advantage |
$117.27
|
| Rate for Payer: Priority Health Choice Medicaid |
$78.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$288.40
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$213.43
|
| Rate for Payer: Priority Health Medicare |
$117.27
|
| Rate for Payer: Priority Health Narrow Network |
$213.43
|
| Rate for Payer: UHC Medicare Advantage |
$120.79
|
|
|
PR EXC LES MUCOSA & SBMCSL VESTIBULE MOUTH W/O RPR
|
Professional
|
Both
|
$362.00
|
|
|
Service Code
|
HCPCS 40810
|
| Min. Negotiated Rate |
$78.81 |
| Max. Negotiated Rate |
$667.79 |
| Rate for Payer: Aetna Commercial |
$159.49
|
| Rate for Payer: Aetna Medicare |
$119.02
|
| Rate for Payer: BCBS Complete |
$82.75
|
| Rate for Payer: BCBS MAPPO |
$119.02
|
| Rate for Payer: BCBS Trust/PPO |
$667.79
|
| Rate for Payer: BCN Commercial |
$320.09
|
| Rate for Payer: BCN Medicare Advantage |
$119.02
|
| Rate for Payer: Cash Price |
$289.60
|
| Rate for Payer: Cash Price |
$289.60
|
| Rate for Payer: Cofinity Commercial |
$171.39
|
| Rate for Payer: Cofinity Commercial |
$159.49
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$119.02
|
| Rate for Payer: Healthscope Commercial |
$142.82
|
| Rate for Payer: Healthscope Whirlpool |
$142.82
|
| Rate for Payer: Meridian Medicaid |
$82.75
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$124.97
|
| Rate for Payer: PACE SWMI |
$119.02
|
| Rate for Payer: PHP Medicare Advantage |
$119.02
|
| Rate for Payer: Priority Health Choice Medicaid |
$78.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$253.40
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$216.96
|
| Rate for Payer: Priority Health Medicare |
$119.02
|
| Rate for Payer: Priority Health Narrow Network |
$216.96
|
| Rate for Payer: UHC Medicare Advantage |
$122.59
|
|
|
PR EXC LIP FULL THKNS RCNSTJ W/LOCAL FLAP
|
Professional
|
Both
|
$1,944.00
|
|
|
Service Code
|
HCPCS 40525
|
| Min. Negotiated Rate |
$355.28 |
| Max. Negotiated Rate |
$1,360.80 |
| Rate for Payer: Aetna Commercial |
$724.82
|
| Rate for Payer: Aetna Medicare |
$540.91
|
| Rate for Payer: BCBS Complete |
$373.04
|
| Rate for Payer: BCBS MAPPO |
$540.91
|
| Rate for Payer: BCBS Trust/PPO |
$774.49
|
| Rate for Payer: BCN Commercial |
$808.76
|
| Rate for Payer: BCN Medicare Advantage |
$540.91
|
| Rate for Payer: Cash Price |
$1,555.20
|
| Rate for Payer: Cash Price |
$1,555.20
|
| Rate for Payer: Cofinity Commercial |
$724.82
|
| Rate for Payer: Cofinity Commercial |
$778.91
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$540.91
|
| Rate for Payer: Healthscope Commercial |
$649.09
|
| Rate for Payer: Healthscope Whirlpool |
$649.09
|
| Rate for Payer: Meridian Medicaid |
$373.04
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$567.96
|
| Rate for Payer: PACE SWMI |
$540.91
|
| Rate for Payer: PHP Medicare Advantage |
$540.91
|
| Rate for Payer: Priority Health Choice Medicaid |
$355.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,360.80
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$973.09
|
| Rate for Payer: Priority Health Medicare |
$540.91
|
| Rate for Payer: Priority Health Narrow Network |
$973.09
|
| Rate for Payer: UHC Medicare Advantage |
$557.14
|
|
|
PR EXC LIP TRANSVRS WEDGE EXC W/PRIM CLSR
|
Professional
|
Both
|
$712.00
|
|
|
Service Code
|
HCPCS 40510
|
| Min. Negotiated Rate |
$225.14 |
| Max. Negotiated Rate |
$719.83 |
| Rate for Payer: Aetna Commercial |
$457.05
|
| Rate for Payer: Aetna Medicare |
$341.08
|
| Rate for Payer: BCBS Complete |
$236.40
|
| Rate for Payer: BCBS MAPPO |
$341.08
|
| Rate for Payer: BCBS Trust/PPO |
$378.26
|
| Rate for Payer: BCN Commercial |
$719.83
|
| Rate for Payer: BCN Medicare Advantage |
$341.08
|
| Rate for Payer: Cash Price |
$569.60
|
| Rate for Payer: Cash Price |
$569.60
|
| Rate for Payer: Cofinity Commercial |
$491.16
|
| Rate for Payer: Cofinity Commercial |
$457.05
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$341.08
|
| Rate for Payer: Healthscope Commercial |
$409.30
|
| Rate for Payer: Healthscope Whirlpool |
$409.30
|
| Rate for Payer: Meridian Medicaid |
$236.40
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$358.13
|
| Rate for Payer: PACE SWMI |
$341.08
|
| Rate for Payer: PHP Medicare Advantage |
$341.08
|
| Rate for Payer: Priority Health Choice Medicaid |
$225.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$498.40
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$615.02
|
| Rate for Payer: Priority Health Medicare |
$341.08
|
| Rate for Payer: Priority Health Narrow Network |
$615.02
|
| Rate for Payer: UHC Medicare Advantage |
$351.31
|
|
|
PR EXC LIP V-EXC W/PRIM DIR LINR CLSR
|
Professional
|
Both
|
$1,161.00
|
|
|
Service Code
|
HCPCS 40520
|
| Min. Negotiated Rate |
$230.04 |
| Max. Negotiated Rate |
$812.70 |
| Rate for Payer: Aetna Commercial |
$469.46
|
| Rate for Payer: Aetna Medicare |
$350.34
|
| Rate for Payer: BCBS Complete |
$241.54
|
| Rate for Payer: BCBS MAPPO |
$350.34
|
| Rate for Payer: BCBS Trust/PPO |
$423.17
|
| Rate for Payer: BCN Commercial |
$744.75
|
| Rate for Payer: BCN Medicare Advantage |
$350.34
|
| Rate for Payer: Cash Price |
$928.80
|
| Rate for Payer: Cash Price |
$928.80
|
| Rate for Payer: Cofinity Commercial |
$504.49
|
| Rate for Payer: Cofinity Commercial |
$469.46
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$350.34
|
| Rate for Payer: Healthscope Commercial |
$420.41
|
| Rate for Payer: Healthscope Whirlpool |
$420.41
|
| Rate for Payer: Meridian Medicaid |
$241.54
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$367.86
|
| Rate for Payer: PACE SWMI |
$350.34
|
| Rate for Payer: PHP Medicare Advantage |
$350.34
|
| Rate for Payer: Priority Health Choice Medicaid |
$230.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$812.70
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$632.08
|
| Rate for Payer: Priority Health Medicare |
$350.34
|
| Rate for Payer: Priority Health Narrow Network |
$632.08
|
| Rate for Payer: UHC Medicare Advantage |
$360.85
|
|
|
PR EXC LOCAL MALIGNANT TUMOR STOMACH
|
Professional
|
Both
|
$1,807.00
|
|
|
Service Code
|
HCPCS 43611
|
| Min. Negotiated Rate |
$785.76 |
| Max. Negotiated Rate |
$2,153.75 |
| Rate for Payer: Aetna Commercial |
$1,634.06
|
| Rate for Payer: Aetna Medicare |
$1,219.45
|
| Rate for Payer: BCBS Complete |
$825.05
|
| Rate for Payer: BCBS MAPPO |
$1,219.45
|
| Rate for Payer: BCBS Trust/PPO |
$787.17
|
| Rate for Payer: BCN Commercial |
$1,790.02
|
| Rate for Payer: BCN Medicare Advantage |
$1,219.45
|
| Rate for Payer: Cash Price |
$1,445.60
|
| Rate for Payer: Cash Price |
$1,445.60
|
| Rate for Payer: Cofinity Commercial |
$1,634.06
|
| Rate for Payer: Cofinity Commercial |
$1,756.01
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,219.45
|
| Rate for Payer: Healthscope Commercial |
$1,463.34
|
| Rate for Payer: Healthscope Whirlpool |
$1,463.34
|
| Rate for Payer: Meridian Medicaid |
$825.05
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$1,280.42
|
| Rate for Payer: PACE SWMI |
$1,219.45
|
| Rate for Payer: PHP Medicare Advantage |
$1,219.45
|
| Rate for Payer: Priority Health Choice Medicaid |
$785.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,264.90
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2,153.75
|
| Rate for Payer: Priority Health Medicare |
$1,219.45
|
| Rate for Payer: Priority Health Narrow Network |
$2,153.75
|
| Rate for Payer: UHC Medicare Advantage |
$1,256.03
|
|
|
PR EXC LOCAL ULCER/BENIGN TUMOR STOMACH
|
Professional
|
Both
|
$3,097.00
|
|
|
Service Code
|
HCPCS 43610
|
| Min. Negotiated Rate |
$625.37 |
| Max. Negotiated Rate |
$2,167.90 |
| Rate for Payer: Aetna Commercial |
$1,305.96
|
| Rate for Payer: Aetna Medicare |
$974.60
|
| Rate for Payer: BCBS Complete |
$656.64
|
| Rate for Payer: BCBS MAPPO |
$974.60
|
| Rate for Payer: BCBS Trust/PPO |
$686.26
|
| Rate for Payer: BCN Commercial |
$1,429.87
|
| Rate for Payer: BCN Medicare Advantage |
$974.60
|
| Rate for Payer: Cash Price |
$2,477.60
|
| Rate for Payer: Cash Price |
$2,477.60
|
| Rate for Payer: Cofinity Commercial |
$1,403.42
|
| Rate for Payer: Cofinity Commercial |
$1,305.96
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$974.60
|
| Rate for Payer: Healthscope Commercial |
$1,169.52
|
| Rate for Payer: Healthscope Whirlpool |
$1,169.52
|
| Rate for Payer: Meridian Medicaid |
$656.64
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$1,023.33
|
| Rate for Payer: PACE SWMI |
$974.60
|
| Rate for Payer: PHP Medicare Advantage |
$974.60
|
| Rate for Payer: Priority Health Choice Medicaid |
$625.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,167.90
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,720.41
|
| Rate for Payer: Priority Health Medicare |
$974.60
|
| Rate for Payer: Priority Health Narrow Network |
$1,720.41
|
| Rate for Payer: UHC Medicare Advantage |
$1,003.84
|
|
|
PR EXCLUSION LAA OPEN TM STRNT/THRCM ANY METHOD
|
Professional
|
Both
|
$286.00
|
|
|
Service Code
|
HCPCS 33268
|
| Min. Negotiated Rate |
$80.73 |
| Max. Negotiated Rate |
$1,025.43 |
| Rate for Payer: Aetna Commercial |
$172.32
|
| Rate for Payer: Aetna Medicare |
$128.60
|
| Rate for Payer: BCBS Complete |
$84.77
|
| Rate for Payer: BCBS MAPPO |
$128.60
|
| Rate for Payer: BCBS Trust/PPO |
$1,025.43
|
| Rate for Payer: BCN Commercial |
$186.67
|
| Rate for Payer: BCN Medicare Advantage |
$128.60
|
| Rate for Payer: Cash Price |
$228.80
|
| Rate for Payer: Cash Price |
$228.80
|
| Rate for Payer: Cofinity Commercial |
$185.18
|
| Rate for Payer: Cofinity Commercial |
$172.32
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$128.60
|
| Rate for Payer: Healthscope Commercial |
$154.32
|
| Rate for Payer: Healthscope Whirlpool |
$154.32
|
| Rate for Payer: Meridian Medicaid |
$84.77
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$135.03
|
| Rate for Payer: PACE SWMI |
$128.60
|
| Rate for Payer: PHP Medicare Advantage |
$128.60
|
| Rate for Payer: Priority Health Choice Medicaid |
$80.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$200.20
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$203.21
|
| Rate for Payer: Priority Health Medicare |
$128.60
|
| Rate for Payer: Priority Health Narrow Network |
$203.21
|
| Rate for Payer: UHC Medicare Advantage |
$132.46
|
|
|
PR EXCLUSION LEFT ATRIAL APPENDAGE OPEN ANY METHOD
|
Professional
|
Both
|
$2,082.00
|
|
|
Service Code
|
HCPCS 33267
|
| Min. Negotiated Rate |
$656.04 |
| Max. Negotiated Rate |
$5,381.79 |
| Rate for Payer: Aetna Commercial |
$1,373.66
|
| Rate for Payer: Aetna Medicare |
$1,025.12
|
| Rate for Payer: BCBS Complete |
$688.84
|
| Rate for Payer: BCBS MAPPO |
$1,025.12
|
| Rate for Payer: BCBS Trust/PPO |
$5,381.79
|
| Rate for Payer: BCN Commercial |
$1,497.31
|
| Rate for Payer: BCN Medicare Advantage |
$1,025.12
|
| Rate for Payer: Cash Price |
$1,665.60
|
| Rate for Payer: Cash Price |
$1,665.60
|
| Rate for Payer: Cofinity Commercial |
$1,476.17
|
| Rate for Payer: Cofinity Commercial |
$1,373.66
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,025.12
|
| Rate for Payer: Healthscope Commercial |
$1,230.14
|
| Rate for Payer: Healthscope Whirlpool |
$1,230.14
|
| Rate for Payer: Meridian Medicaid |
$688.84
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$1,076.38
|
| Rate for Payer: PACE SWMI |
$1,025.12
|
| Rate for Payer: PHP Medicare Advantage |
$1,025.12
|
| Rate for Payer: Priority Health Choice Medicaid |
$656.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,457.40
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,629.91
|
| Rate for Payer: Priority Health Medicare |
$1,025.12
|
| Rate for Payer: Priority Health Narrow Network |
$1,629.91
|
| Rate for Payer: UHC Medicare Advantage |
$1,055.87
|
|
|
PR EXC MECKEL'S DIVERTICULUM/OMPHALOMESENTERIC DUCT
|
Facility
|
OP
|
$2,073.00
|
|
|
Service Code
|
CPT 44800
|
| Hospital Charge Code |
44800
|
| Min. Negotiated Rate |
$829.20 |
| Max. Negotiated Rate |
$2,073.00 |
| Rate for Payer: Aetna Commercial |
$1,865.70
|
| Rate for Payer: ASR ASR |
$2,010.81
|
| Rate for Payer: BCBS Complete |
$829.20
|
| Rate for Payer: BCBS Trust/PPO |
$1,607.20
|
| Rate for Payer: BCN Commercial |
$1,607.20
|
| Rate for Payer: Cash Price |
$1,658.40
|
| Rate for Payer: Cofinity Commercial |
$1,948.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,658.40
|
| Rate for Payer: Healthscope Commercial |
$2,073.00
|
| Rate for Payer: Healthscope Whirlpool |
$2,010.81
|
| Rate for Payer: Mclaren Commercial |
$1,865.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,762.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,451.10
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,886.43
|
| Rate for Payer: Priority Health Narrow Network |
$1,471.83
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1,824.24
|
|
|
PR EXC MECKEL'S DIVERTICULUM/OMPHALOMESENTERIC DUCT
|
Professional
|
Both
|
$2,073.00
|
|
|
Service Code
|
HCPCS 44800
|
| Min. Negotiated Rate |
$332.30 |
| Max. Negotiated Rate |
$1,451.10 |
| Rate for Payer: Aetna Commercial |
$1,029.07
|
| Rate for Payer: Aetna Medicare |
$767.96
|
| Rate for Payer: BCBS Complete |
$523.79
|
| Rate for Payer: BCBS MAPPO |
$767.96
|
| Rate for Payer: BCBS Trust/PPO |
$332.30
|
| Rate for Payer: BCN Commercial |
$1,133.25
|
| Rate for Payer: BCN Medicare Advantage |
$767.96
|
| Rate for Payer: Cash Price |
$1,658.40
|
| Rate for Payer: Cash Price |
$1,658.40
|
| Rate for Payer: Cofinity Commercial |
$1,029.07
|
| Rate for Payer: Cofinity Commercial |
$1,105.86
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$767.96
|
| Rate for Payer: Healthscope Commercial |
$921.55
|
| Rate for Payer: Healthscope Whirlpool |
$921.55
|
| Rate for Payer: Meridian Medicaid |
$523.79
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$806.36
|
| Rate for Payer: PACE SWMI |
$767.96
|
| Rate for Payer: PHP Medicare Advantage |
$767.96
|
| Rate for Payer: Priority Health Choice Medicaid |
$498.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,451.10
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,363.50
|
| Rate for Payer: Priority Health Medicare |
$767.96
|
| Rate for Payer: Priority Health Narrow Network |
$1,363.50
|
| Rate for Payer: UHC Medicare Advantage |
$791.00
|
|
|
PR EXC MECKEL'S DIVERTICULUM/OMPHALOMESENTERIC DUCT
|
Facility
|
IP
|
$2,073.00
|
|
|
Service Code
|
CPT 44800
|
| Hospital Charge Code |
44800
|
| Min. Negotiated Rate |
$1,451.10 |
| Max. Negotiated Rate |
$2,073.00 |
| Rate for Payer: Aetna Commercial |
$1,865.70
|
| Rate for Payer: ASR ASR |
$2,010.81
|
| Rate for Payer: BCBS Trust/PPO |
$1,607.20
|
| Rate for Payer: BCN Commercial |
$1,607.20
|
| Rate for Payer: Cash Price |
$1,658.40
|
| Rate for Payer: Cofinity Commercial |
$1,948.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,658.40
|
| Rate for Payer: Healthscope Commercial |
$2,073.00
|
| Rate for Payer: Healthscope Whirlpool |
$2,010.81
|
| Rate for Payer: Mclaren Commercial |
$1,865.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,762.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,451.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1,824.24
|
|
|
PR EXC MECKEL'S DIVERTICULUM/OMPHALOMESENTERIC DUCT
|
Professional
|
Both
|
$2,073.00
|
|
|
Service Code
|
HCPCS 44800
|
| Hospital Charge Code |
44800
|
| Min. Negotiated Rate |
$332.30 |
| Max. Negotiated Rate |
$1,451.10 |
| Rate for Payer: Aetna Commercial |
$1,029.07
|
| Rate for Payer: Aetna Medicare |
$767.96
|
| Rate for Payer: BCBS Complete |
$523.79
|
| Rate for Payer: BCBS MAPPO |
$767.96
|
| Rate for Payer: BCBS Trust/PPO |
$332.30
|
| Rate for Payer: BCN Commercial |
$1,133.25
|
| Rate for Payer: BCN Medicare Advantage |
$767.96
|
| Rate for Payer: Cash Price |
$1,658.40
|
| Rate for Payer: Cash Price |
$1,658.40
|
| Rate for Payer: Cofinity Commercial |
$1,105.86
|
| Rate for Payer: Cofinity Commercial |
$1,029.07
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$767.96
|
| Rate for Payer: Healthscope Commercial |
$921.55
|
| Rate for Payer: Healthscope Whirlpool |
$921.55
|
| Rate for Payer: Meridian Medicaid |
$523.79
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$806.36
|
| Rate for Payer: PACE SWMI |
$767.96
|
| Rate for Payer: PHP Medicare Advantage |
$767.96
|
| Rate for Payer: Priority Health Choice Medicaid |
$498.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,451.10
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,363.50
|
| Rate for Payer: Priority Health Medicare |
$767.96
|
| Rate for Payer: Priority Health Narrow Network |
$1,363.50
|
| Rate for Payer: UHC Medicare Advantage |
$791.00
|
|
