|
PR INJECTION 1 TENDON SHEATH/LIGAMENT APONEUROSIS
|
Facility
|
IP
|
$145.00
|
|
|
Service Code
|
CPT 20550
|
| Hospital Charge Code |
20550
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$94.25 |
| Max. Negotiated Rate |
$145.00 |
| Rate for Payer: Aetna Commercial |
$130.50
|
| Rate for Payer: ASR ASR |
$140.65
|
| Rate for Payer: ASR Commercial |
$140.65
|
| Rate for Payer: BCBS Trust/PPO |
$118.16
|
| Rate for Payer: BCN Commercial |
$112.42
|
| Rate for Payer: Cash Price |
$116.00
|
| Rate for Payer: Cofinity Commercial |
$136.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$116.00
|
| Rate for Payer: Healthscope Commercial |
$145.00
|
| Rate for Payer: Healthscope Whirlpool |
$140.65
|
| Rate for Payer: Mclaren Commercial |
$130.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$123.25
|
| Rate for Payer: Nomi Health Commercial |
$118.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$94.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$127.60
|
|
|
PR INJECTION 1 TENDON SHEATH/LIGAMENT APONEUROSIS
|
Facility
|
OP
|
$145.00
|
|
|
Service Code
|
CPT 20550
|
| Hospital Charge Code |
20550
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$94.25 |
| Max. Negotiated Rate |
$446.23 |
| Rate for Payer: Aetna Commercial |
$130.50
|
| Rate for Payer: Aetna Medicare |
$287.89
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$359.86
|
| Rate for Payer: Amish Plain Church Group Commercial |
$359.86
|
| Rate for Payer: ASR ASR |
$140.65
|
| Rate for Payer: ASR Commercial |
$140.65
|
| Rate for Payer: BCBS Complete |
$162.02
|
| Rate for Payer: BCBS MAPPO |
$287.89
|
| Rate for Payer: BCBS Trust/PPO |
$118.74
|
| Rate for Payer: BCN Commercial |
$112.42
|
| Rate for Payer: BCN Medicare Advantage |
$287.89
|
| Rate for Payer: Cash Price |
$116.00
|
| Rate for Payer: Cash Price |
$116.00
|
| Rate for Payer: Cofinity Commercial |
$136.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$116.00
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$287.89
|
| Rate for Payer: Healthscope Commercial |
$145.00
|
| Rate for Payer: Healthscope Whirlpool |
$140.65
|
| Rate for Payer: Humana Choice PPO Medicare |
$287.89
|
| Rate for Payer: Mclaren Commercial |
$130.50
|
| Rate for Payer: Mclaren Medicaid |
$154.31
|
| Rate for Payer: Mclaren Medicare |
$287.89
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$302.28
|
| Rate for Payer: Meridian Medicaid |
$162.02
|
| Rate for Payer: MI Amish Medical Board Commercial |
$331.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$123.25
|
| Rate for Payer: Nomi Health Commercial |
$118.90
|
| Rate for Payer: PACE Medicare |
$273.50
|
| Rate for Payer: PACE SWMI |
$287.89
|
| Rate for Payer: PHP Commercial |
$316.68
|
| Rate for Payer: PHP Medicaid |
$154.31
|
| Rate for Payer: PHP Medicare Advantage |
$287.89
|
| Rate for Payer: Priority Health Choice Medicaid |
$154.31
|
| Rate for Payer: Priority Health Cigna Priority Health |
$94.25
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$127.05
|
| Rate for Payer: Priority Health Medicare |
$287.89
|
| Rate for Payer: Priority Health Narrow Network |
$101.64
|
| Rate for Payer: Railroad Medicare Medicare |
$287.89
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$127.60
|
| Rate for Payer: UHC Dual Complete DSNP |
$287.89
|
| Rate for Payer: UHC Exchange |
$446.23
|
| Rate for Payer: UHC Medicare Advantage |
$287.89
|
| Rate for Payer: UHCCP DNSP |
$287.89
|
| Rate for Payer: UHCCP Medicaid |
$154.31
|
| Rate for Payer: VA VA |
$287.89
|
|
|
PR INJECTION 1 TENDON SHEATH/LIGAMENT APONEUROSIS
|
Professional
|
Both
|
$145.00
|
|
|
Service Code
|
HCPCS 20550
|
| Hospital Charge Code |
20550
|
| Min. Negotiated Rate |
$37.48 |
| Max. Negotiated Rate |
$94.25 |
| Rate for Payer: Aetna Commercial |
$50.22
|
| Rate for Payer: Aetna Medicare |
$37.48
|
| Rate for Payer: BCBS Complete |
$58.00
|
| Rate for Payer: BCBS MAPPO |
$37.48
|
| Rate for Payer: BCN Medicare Advantage |
$37.48
|
| Rate for Payer: Cash Price |
$116.00
|
| Rate for Payer: Cash Price |
$116.00
|
| Rate for Payer: Cofinity Commercial |
$53.97
|
| Rate for Payer: Cofinity Commercial |
$50.22
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$37.48
|
| Rate for Payer: Healthscope Commercial |
$44.98
|
| Rate for Payer: Healthscope Whirlpool |
$44.98
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$39.35
|
| Rate for Payer: Nomi Health Commercial |
$44.98
|
| Rate for Payer: PACE SWMI |
$37.48
|
| Rate for Payer: PHP Medicare Advantage |
$37.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$94.25
|
| Rate for Payer: Priority Health Medicare |
$37.48
|
| Rate for Payer: UHC Dual Complete DSNP |
$37.48
|
| Rate for Payer: UHC Medicare Advantage |
$37.48
|
| Rate for Payer: UHCCP DNSP |
$37.48
|
|
|
PR INJECTION AA&/STRD AXILLARY NERVE W/IMG GDN
|
Professional
|
Both
|
$289.00
|
|
|
Service Code
|
HCPCS 64417
|
| Min. Negotiated Rate |
$61.75 |
| Max. Negotiated Rate |
$187.85 |
| Rate for Payer: Aetna Commercial |
$82.75
|
| Rate for Payer: Aetna Medicare |
$61.75
|
| Rate for Payer: BCBS Complete |
$115.60
|
| Rate for Payer: BCBS MAPPO |
$61.75
|
| Rate for Payer: BCN Medicare Advantage |
$61.75
|
| Rate for Payer: Cash Price |
$231.20
|
| Rate for Payer: Cash Price |
$231.20
|
| Rate for Payer: Cofinity Commercial |
$88.92
|
| Rate for Payer: Cofinity Commercial |
$82.75
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$61.75
|
| Rate for Payer: Healthscope Commercial |
$74.10
|
| Rate for Payer: Healthscope Whirlpool |
$74.10
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$64.84
|
| Rate for Payer: Nomi Health Commercial |
$74.10
|
| Rate for Payer: PACE SWMI |
$61.75
|
| Rate for Payer: PHP Medicare Advantage |
$61.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$187.85
|
| Rate for Payer: Priority Health Medicare |
$61.75
|
| Rate for Payer: UHC Dual Complete DSNP |
$61.75
|
| Rate for Payer: UHC Medicare Advantage |
$61.75
|
| Rate for Payer: UHCCP DNSP |
$61.75
|
|
|
PR INJECTION AA&/STRD BRACHIAL PLEXUS W/IMG GDN
|
Professional
|
Both
|
$524.00
|
|
|
Service Code
|
HCPCS 64415
|
| Min. Negotiated Rate |
$66.71 |
| Max. Negotiated Rate |
$340.60 |
| Rate for Payer: Aetna Commercial |
$89.39
|
| Rate for Payer: Aetna Medicare |
$66.71
|
| Rate for Payer: BCBS Complete |
$209.60
|
| Rate for Payer: BCBS MAPPO |
$66.71
|
| Rate for Payer: BCN Medicare Advantage |
$66.71
|
| Rate for Payer: Cash Price |
$419.20
|
| Rate for Payer: Cash Price |
$419.20
|
| Rate for Payer: Cofinity Commercial |
$96.06
|
| Rate for Payer: Cofinity Commercial |
$89.39
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$66.71
|
| Rate for Payer: Healthscope Commercial |
$80.05
|
| Rate for Payer: Healthscope Whirlpool |
$80.05
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$70.05
|
| Rate for Payer: Nomi Health Commercial |
$80.05
|
| Rate for Payer: PACE SWMI |
$66.71
|
| Rate for Payer: PHP Medicare Advantage |
$66.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$340.60
|
| Rate for Payer: Priority Health Medicare |
$66.71
|
| Rate for Payer: UHC Dual Complete DSNP |
$66.71
|
| Rate for Payer: UHC Medicare Advantage |
$66.71
|
| Rate for Payer: UHCCP DNSP |
$66.71
|
|
|
PR INJECTION AA&/STRD FEMORAL NERVE W/IMG GDN
|
Professional
|
Both
|
$184.00
|
|
|
Service Code
|
HCPCS 64447
|
| Min. Negotiated Rate |
$60.95 |
| Max. Negotiated Rate |
$119.60 |
| Rate for Payer: Aetna Commercial |
$81.67
|
| Rate for Payer: Aetna Medicare |
$60.95
|
| Rate for Payer: BCBS Complete |
$73.60
|
| Rate for Payer: BCBS MAPPO |
$60.95
|
| Rate for Payer: BCN Medicare Advantage |
$60.95
|
| Rate for Payer: Cash Price |
$147.20
|
| Rate for Payer: Cash Price |
$147.20
|
| Rate for Payer: Cofinity Commercial |
$87.77
|
| Rate for Payer: Cofinity Commercial |
$81.67
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$60.95
|
| Rate for Payer: Healthscope Commercial |
$73.14
|
| Rate for Payer: Healthscope Whirlpool |
$73.14
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$64.00
|
| Rate for Payer: Nomi Health Commercial |
$73.14
|
| Rate for Payer: PACE SWMI |
$60.95
|
| Rate for Payer: PHP Medicare Advantage |
$60.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$119.60
|
| Rate for Payer: Priority Health Medicare |
$60.95
|
| Rate for Payer: UHC Dual Complete DSNP |
$60.95
|
| Rate for Payer: UHC Medicare Advantage |
$60.95
|
| Rate for Payer: UHCCP DNSP |
$60.95
|
|
|
PR INJECTION AA&/STRD GENICULAR NRV BRANCHES W/IMG
|
Professional
|
Both
|
$416.00
|
|
|
Service Code
|
HCPCS 64454
|
| Hospital Charge Code |
64454
|
| Min. Negotiated Rate |
$78.43 |
| Max. Negotiated Rate |
$270.40 |
| Rate for Payer: Aetna Commercial |
$105.10
|
| Rate for Payer: Aetna Medicare |
$78.43
|
| Rate for Payer: BCBS Complete |
$166.40
|
| Rate for Payer: BCBS MAPPO |
$78.43
|
| Rate for Payer: BCN Medicare Advantage |
$78.43
|
| Rate for Payer: Cash Price |
$332.80
|
| Rate for Payer: Cash Price |
$332.80
|
| Rate for Payer: Cofinity Commercial |
$112.94
|
| Rate for Payer: Cofinity Commercial |
$105.10
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$78.43
|
| Rate for Payer: Healthscope Commercial |
$94.12
|
| Rate for Payer: Healthscope Whirlpool |
$94.12
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$82.35
|
| Rate for Payer: Nomi Health Commercial |
$94.12
|
| Rate for Payer: PACE SWMI |
$78.43
|
| Rate for Payer: PHP Medicare Advantage |
$78.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$270.40
|
| Rate for Payer: Priority Health Medicare |
$78.43
|
| Rate for Payer: UHC Dual Complete DSNP |
$78.43
|
| Rate for Payer: UHC Medicare Advantage |
$78.43
|
| Rate for Payer: UHCCP DNSP |
$78.43
|
|
|
PR INJECTION AA&/STRD GENICULAR NRV BRANCHES W/IMG
|
Facility
|
IP
|
$416.00
|
|
|
Service Code
|
CPT 64454
|
| Hospital Charge Code |
64454
|
| Min. Negotiated Rate |
$270.40 |
| Max. Negotiated Rate |
$416.00 |
| Rate for Payer: Aetna Commercial |
$374.40
|
| Rate for Payer: ASR ASR |
$403.52
|
| Rate for Payer: ASR Commercial |
$403.52
|
| Rate for Payer: BCBS Trust/PPO |
$339.00
|
| Rate for Payer: BCN Commercial |
$322.52
|
| Rate for Payer: Cash Price |
$332.80
|
| Rate for Payer: Cofinity Commercial |
$391.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$332.80
|
| Rate for Payer: Healthscope Commercial |
$416.00
|
| Rate for Payer: Healthscope Whirlpool |
$403.52
|
| Rate for Payer: Mclaren Commercial |
$374.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$353.60
|
| Rate for Payer: Nomi Health Commercial |
$341.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$270.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$366.08
|
|
|
PR INJECTION AA&/STRD GENICULAR NRV BRANCHES W/IMG
|
Professional
|
Both
|
$416.00
|
|
|
Service Code
|
HCPCS 64454
|
| Min. Negotiated Rate |
$78.43 |
| Max. Negotiated Rate |
$270.40 |
| Rate for Payer: Aetna Commercial |
$105.10
|
| Rate for Payer: Aetna Medicare |
$78.43
|
| Rate for Payer: BCBS Complete |
$166.40
|
| Rate for Payer: BCBS MAPPO |
$78.43
|
| Rate for Payer: BCN Medicare Advantage |
$78.43
|
| Rate for Payer: Cash Price |
$332.80
|
| Rate for Payer: Cash Price |
$332.80
|
| Rate for Payer: Cofinity Commercial |
$112.94
|
| Rate for Payer: Cofinity Commercial |
$105.10
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$78.43
|
| Rate for Payer: Healthscope Commercial |
$94.12
|
| Rate for Payer: Healthscope Whirlpool |
$94.12
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$82.35
|
| Rate for Payer: Nomi Health Commercial |
$94.12
|
| Rate for Payer: PACE SWMI |
$78.43
|
| Rate for Payer: PHP Medicare Advantage |
$78.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$270.40
|
| Rate for Payer: Priority Health Medicare |
$78.43
|
| Rate for Payer: UHC Dual Complete DSNP |
$78.43
|
| Rate for Payer: UHC Medicare Advantage |
$78.43
|
| Rate for Payer: UHCCP DNSP |
$78.43
|
|
|
PR INJECTION AA&/STRD GENICULAR NRV BRANCHES W/IMG
|
Facility
|
OP
|
$416.00
|
|
|
Service Code
|
CPT 64454
|
| Hospital Charge Code |
64454
|
| Min. Negotiated Rate |
$270.40 |
| Max. Negotiated Rate |
$1,046.87 |
| Rate for Payer: Aetna Commercial |
$374.40
|
| Rate for Payer: Aetna Medicare |
$675.40
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$844.25
|
| Rate for Payer: Amish Plain Church Group Commercial |
$844.25
|
| Rate for Payer: ASR ASR |
$403.52
|
| Rate for Payer: ASR Commercial |
$403.52
|
| Rate for Payer: BCBS Complete |
$380.12
|
| Rate for Payer: BCBS MAPPO |
$675.40
|
| Rate for Payer: BCBS Trust/PPO |
$340.66
|
| Rate for Payer: BCN Commercial |
$322.52
|
| Rate for Payer: BCN Medicare Advantage |
$675.40
|
| Rate for Payer: Cash Price |
$332.80
|
| Rate for Payer: Cash Price |
$332.80
|
| Rate for Payer: Cofinity Commercial |
$391.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$332.80
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$675.40
|
| Rate for Payer: Healthscope Commercial |
$416.00
|
| Rate for Payer: Healthscope Whirlpool |
$403.52
|
| Rate for Payer: Humana Choice PPO Medicare |
$675.40
|
| Rate for Payer: Mclaren Commercial |
$374.40
|
| Rate for Payer: Mclaren Medicaid |
$362.01
|
| Rate for Payer: Mclaren Medicare |
$675.40
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$709.17
|
| Rate for Payer: Meridian Medicaid |
$380.12
|
| Rate for Payer: MI Amish Medical Board Commercial |
$776.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$353.60
|
| Rate for Payer: Nomi Health Commercial |
$341.12
|
| Rate for Payer: PACE Medicare |
$641.63
|
| Rate for Payer: PACE SWMI |
$675.40
|
| Rate for Payer: PHP Commercial |
$742.94
|
| Rate for Payer: PHP Medicaid |
$362.01
|
| Rate for Payer: PHP Medicare Advantage |
$675.40
|
| Rate for Payer: Priority Health Choice Medicaid |
$362.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$270.40
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$364.50
|
| Rate for Payer: Priority Health Medicare |
$675.40
|
| Rate for Payer: Priority Health Narrow Network |
$291.62
|
| Rate for Payer: Railroad Medicare Medicare |
$675.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$366.08
|
| Rate for Payer: UHC Dual Complete DSNP |
$675.40
|
| Rate for Payer: UHC Exchange |
$1,046.87
|
| Rate for Payer: UHC Medicare Advantage |
$675.40
|
| Rate for Payer: UHCCP DNSP |
$675.40
|
| Rate for Payer: UHCCP Medicaid |
$362.01
|
| Rate for Payer: VA VA |
$675.40
|
|
|
PR INJECTION AA&/STRD GREATER OCCIPITAL NERVE
|
Facility
|
OP
|
$502.00
|
|
|
Service Code
|
CPT 64405
|
| Hospital Charge Code |
64405
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$154.31 |
| Max. Negotiated Rate |
$502.00 |
| Rate for Payer: Aetna Commercial |
$451.80
|
| Rate for Payer: Aetna Medicare |
$287.89
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$359.86
|
| Rate for Payer: Amish Plain Church Group Commercial |
$359.86
|
| Rate for Payer: ASR ASR |
$486.94
|
| Rate for Payer: ASR Commercial |
$486.94
|
| Rate for Payer: BCBS Complete |
$162.02
|
| Rate for Payer: BCBS MAPPO |
$287.89
|
| Rate for Payer: BCBS Trust/PPO |
$411.09
|
| Rate for Payer: BCN Commercial |
$389.20
|
| Rate for Payer: BCN Medicare Advantage |
$287.89
|
| Rate for Payer: Cash Price |
$401.60
|
| Rate for Payer: Cash Price |
$401.60
|
| Rate for Payer: Cofinity Commercial |
$471.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$401.60
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$287.89
|
| Rate for Payer: Healthscope Commercial |
$502.00
|
| Rate for Payer: Healthscope Whirlpool |
$486.94
|
| Rate for Payer: Humana Choice PPO Medicare |
$287.89
|
| Rate for Payer: Mclaren Commercial |
$451.80
|
| Rate for Payer: Mclaren Medicaid |
$154.31
|
| Rate for Payer: Mclaren Medicare |
$287.89
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$302.28
|
| Rate for Payer: Meridian Medicaid |
$162.02
|
| Rate for Payer: MI Amish Medical Board Commercial |
$331.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$426.70
|
| Rate for Payer: Nomi Health Commercial |
$411.64
|
| Rate for Payer: PACE Medicare |
$273.50
|
| Rate for Payer: PACE SWMI |
$287.89
|
| Rate for Payer: PHP Commercial |
$316.68
|
| Rate for Payer: PHP Medicaid |
$154.31
|
| Rate for Payer: PHP Medicare Advantage |
$287.89
|
| Rate for Payer: Priority Health Choice Medicaid |
$154.31
|
| Rate for Payer: Priority Health Cigna Priority Health |
$326.30
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$439.85
|
| Rate for Payer: Priority Health Medicare |
$287.89
|
| Rate for Payer: Priority Health Narrow Network |
$351.90
|
| Rate for Payer: Railroad Medicare Medicare |
$287.89
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$441.76
|
| Rate for Payer: UHC Dual Complete DSNP |
$287.89
|
| Rate for Payer: UHC Exchange |
$446.23
|
| Rate for Payer: UHC Medicare Advantage |
$287.89
|
| Rate for Payer: UHCCP DNSP |
$287.89
|
| Rate for Payer: UHCCP Medicaid |
$154.31
|
| Rate for Payer: VA VA |
$287.89
|
|
|
PR INJECTION AA&/STRD GREATER OCCIPITAL NERVE
|
Professional
|
Both
|
$502.00
|
|
|
Service Code
|
HCPCS 64405
|
| Min. Negotiated Rate |
$51.42 |
| Max. Negotiated Rate |
$326.30 |
| Rate for Payer: Aetna Commercial |
$68.90
|
| Rate for Payer: Aetna Medicare |
$51.42
|
| Rate for Payer: BCBS Complete |
$200.80
|
| Rate for Payer: BCBS MAPPO |
$51.42
|
| Rate for Payer: BCN Medicare Advantage |
$51.42
|
| Rate for Payer: Cash Price |
$401.60
|
| Rate for Payer: Cash Price |
$401.60
|
| Rate for Payer: Cofinity Commercial |
$74.04
|
| Rate for Payer: Cofinity Commercial |
$68.90
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$51.42
|
| Rate for Payer: Healthscope Commercial |
$61.70
|
| Rate for Payer: Healthscope Whirlpool |
$61.70
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$53.99
|
| Rate for Payer: Nomi Health Commercial |
$61.70
|
| Rate for Payer: PACE SWMI |
$51.42
|
| Rate for Payer: PHP Medicare Advantage |
$51.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$326.30
|
| Rate for Payer: Priority Health Medicare |
$51.42
|
| Rate for Payer: UHC Dual Complete DSNP |
$51.42
|
| Rate for Payer: UHC Medicare Advantage |
$51.42
|
| Rate for Payer: UHCCP DNSP |
$51.42
|
|
|
PR INJECTION AA&/STRD GREATER OCCIPITAL NERVE
|
Professional
|
Both
|
$502.00
|
|
|
Service Code
|
HCPCS 64405
|
| Hospital Charge Code |
64405
|
| Min. Negotiated Rate |
$51.42 |
| Max. Negotiated Rate |
$326.30 |
| Rate for Payer: Aetna Commercial |
$68.90
|
| Rate for Payer: Aetna Medicare |
$51.42
|
| Rate for Payer: BCBS Complete |
$200.80
|
| Rate for Payer: BCBS MAPPO |
$51.42
|
| Rate for Payer: BCN Medicare Advantage |
$51.42
|
| Rate for Payer: Cash Price |
$401.60
|
| Rate for Payer: Cash Price |
$401.60
|
| Rate for Payer: Cofinity Commercial |
$74.04
|
| Rate for Payer: Cofinity Commercial |
$68.90
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$51.42
|
| Rate for Payer: Healthscope Commercial |
$61.70
|
| Rate for Payer: Healthscope Whirlpool |
$61.70
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$53.99
|
| Rate for Payer: Nomi Health Commercial |
$61.70
|
| Rate for Payer: PACE SWMI |
$51.42
|
| Rate for Payer: PHP Medicare Advantage |
$51.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$326.30
|
| Rate for Payer: Priority Health Medicare |
$51.42
|
| Rate for Payer: UHC Dual Complete DSNP |
$51.42
|
| Rate for Payer: UHC Medicare Advantage |
$51.42
|
| Rate for Payer: UHCCP DNSP |
$51.42
|
|
|
PR INJECTION AA&/STRD GREATER OCCIPITAL NERVE
|
Facility
|
IP
|
$502.00
|
|
|
Service Code
|
CPT 64405
|
| Hospital Charge Code |
64405
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$326.30 |
| Max. Negotiated Rate |
$502.00 |
| Rate for Payer: Aetna Commercial |
$451.80
|
| Rate for Payer: ASR ASR |
$486.94
|
| Rate for Payer: ASR Commercial |
$486.94
|
| Rate for Payer: BCBS Trust/PPO |
$409.08
|
| Rate for Payer: BCN Commercial |
$389.20
|
| Rate for Payer: Cash Price |
$401.60
|
| Rate for Payer: Cofinity Commercial |
$471.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$401.60
|
| Rate for Payer: Healthscope Commercial |
$502.00
|
| Rate for Payer: Healthscope Whirlpool |
$486.94
|
| Rate for Payer: Mclaren Commercial |
$451.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$426.70
|
| Rate for Payer: Nomi Health Commercial |
$411.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$326.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$441.76
|
|
|
PR INJECTION AA&/STRD ILIOINGUINAL IH NERVES
|
Professional
|
Both
|
$669.00
|
|
|
Service Code
|
HCPCS 64425
|
| Min. Negotiated Rate |
$51.76 |
| Max. Negotiated Rate |
$434.85 |
| Rate for Payer: Aetna Commercial |
$69.36
|
| Rate for Payer: Aetna Medicare |
$51.76
|
| Rate for Payer: BCBS Complete |
$267.60
|
| Rate for Payer: BCBS MAPPO |
$51.76
|
| Rate for Payer: BCN Medicare Advantage |
$51.76
|
| Rate for Payer: Cash Price |
$535.20
|
| Rate for Payer: Cash Price |
$535.20
|
| Rate for Payer: Cofinity Commercial |
$74.53
|
| Rate for Payer: Cofinity Commercial |
$69.36
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$51.76
|
| Rate for Payer: Healthscope Commercial |
$62.11
|
| Rate for Payer: Healthscope Whirlpool |
$62.11
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$54.35
|
| Rate for Payer: Nomi Health Commercial |
$62.11
|
| Rate for Payer: PACE SWMI |
$51.76
|
| Rate for Payer: PHP Medicare Advantage |
$51.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$434.85
|
| Rate for Payer: Priority Health Medicare |
$51.76
|
| Rate for Payer: UHC Dual Complete DSNP |
$51.76
|
| Rate for Payer: UHC Medicare Advantage |
$51.76
|
| Rate for Payer: UHCCP DNSP |
$51.76
|
|
|
PR INJECTION AA&/STRD INTERCOSTAL NRV EA ADDL LVL
|
Professional
|
Both
|
$204.00
|
|
|
Service Code
|
HCPCS 64421
|
| Min. Negotiated Rate |
$23.29 |
| Max. Negotiated Rate |
$132.60 |
| Rate for Payer: Aetna Commercial |
$31.21
|
| Rate for Payer: Aetna Medicare |
$23.29
|
| Rate for Payer: BCBS Complete |
$81.60
|
| Rate for Payer: BCBS MAPPO |
$23.29
|
| Rate for Payer: BCN Medicare Advantage |
$23.29
|
| Rate for Payer: Cash Price |
$163.20
|
| Rate for Payer: Cash Price |
$163.20
|
| Rate for Payer: Cofinity Commercial |
$33.54
|
| Rate for Payer: Cofinity Commercial |
$31.21
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$23.29
|
| Rate for Payer: Healthscope Commercial |
$27.95
|
| Rate for Payer: Healthscope Whirlpool |
$27.95
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$24.45
|
| Rate for Payer: Nomi Health Commercial |
$27.95
|
| Rate for Payer: PACE SWMI |
$23.29
|
| Rate for Payer: PHP Medicare Advantage |
$23.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$132.60
|
| Rate for Payer: Priority Health Medicare |
$23.29
|
| Rate for Payer: UHC Dual Complete DSNP |
$23.29
|
| Rate for Payer: UHC Medicare Advantage |
$23.29
|
| Rate for Payer: UHCCP DNSP |
$23.29
|
|
|
PR INJECTION AA&/STRD INTERCOSTAL NRV SINGLE LVL
|
Professional
|
Both
|
$219.00
|
|
|
Service Code
|
HCPCS 64420
|
| Min. Negotiated Rate |
$55.99 |
| Max. Negotiated Rate |
$142.35 |
| Rate for Payer: Aetna Commercial |
$75.03
|
| Rate for Payer: Aetna Medicare |
$55.99
|
| Rate for Payer: BCBS Complete |
$87.60
|
| Rate for Payer: BCBS MAPPO |
$55.99
|
| Rate for Payer: BCN Medicare Advantage |
$55.99
|
| Rate for Payer: Cash Price |
$175.20
|
| Rate for Payer: Cash Price |
$175.20
|
| Rate for Payer: Cofinity Commercial |
$80.63
|
| Rate for Payer: Cofinity Commercial |
$75.03
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$55.99
|
| Rate for Payer: Healthscope Commercial |
$67.19
|
| Rate for Payer: Healthscope Whirlpool |
$67.19
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$58.79
|
| Rate for Payer: Nomi Health Commercial |
$67.19
|
| Rate for Payer: PACE SWMI |
$55.99
|
| Rate for Payer: PHP Medicare Advantage |
$55.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$142.35
|
| Rate for Payer: Priority Health Medicare |
$55.99
|
| Rate for Payer: UHC Dual Complete DSNP |
$55.99
|
| Rate for Payer: UHC Medicare Advantage |
$55.99
|
| Rate for Payer: UHCCP DNSP |
$55.99
|
|
|
PR INJECTION AA&/STRD NERVES NRVTG SI JOINT W/IMG
|
Professional
|
Both
|
$414.00
|
|
|
Service Code
|
HCPCS 64451
|
| Min. Negotiated Rate |
$78.14 |
| Max. Negotiated Rate |
$269.10 |
| Rate for Payer: Aetna Commercial |
$104.71
|
| Rate for Payer: Aetna Medicare |
$78.14
|
| Rate for Payer: BCBS Complete |
$165.60
|
| Rate for Payer: BCBS MAPPO |
$78.14
|
| Rate for Payer: BCN Medicare Advantage |
$78.14
|
| Rate for Payer: Cash Price |
$331.20
|
| Rate for Payer: Cash Price |
$331.20
|
| Rate for Payer: Cofinity Commercial |
$112.52
|
| Rate for Payer: Cofinity Commercial |
$104.71
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$78.14
|
| Rate for Payer: Healthscope Commercial |
$93.77
|
| Rate for Payer: Healthscope Whirlpool |
$93.77
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$82.05
|
| Rate for Payer: Nomi Health Commercial |
$93.77
|
| Rate for Payer: PACE SWMI |
$78.14
|
| Rate for Payer: PHP Medicare Advantage |
$78.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$269.10
|
| Rate for Payer: Priority Health Medicare |
$78.14
|
| Rate for Payer: UHC Dual Complete DSNP |
$78.14
|
| Rate for Payer: UHC Medicare Advantage |
$78.14
|
| Rate for Payer: UHCCP DNSP |
$78.14
|
|
|
PR INJECTION AA&/STRD OTHER PERIPHERAL NERVE/BRANCH
|
Facility
|
OP
|
$259.00
|
|
|
Service Code
|
CPT 64450
|
| Hospital Charge Code |
64450
|
| Min. Negotiated Rate |
$168.35 |
| Max. Negotiated Rate |
$1,046.87 |
| Rate for Payer: Aetna Commercial |
$233.10
|
| Rate for Payer: Aetna Medicare |
$675.40
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$844.25
|
| Rate for Payer: Amish Plain Church Group Commercial |
$844.25
|
| Rate for Payer: ASR ASR |
$251.23
|
| Rate for Payer: ASR Commercial |
$251.23
|
| Rate for Payer: BCBS Complete |
$380.12
|
| Rate for Payer: BCBS MAPPO |
$675.40
|
| Rate for Payer: BCBS Trust/PPO |
$212.10
|
| Rate for Payer: BCN Commercial |
$200.80
|
| Rate for Payer: BCN Medicare Advantage |
$675.40
|
| Rate for Payer: Cash Price |
$207.20
|
| Rate for Payer: Cash Price |
$207.20
|
| Rate for Payer: Cofinity Commercial |
$243.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$207.20
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$675.40
|
| Rate for Payer: Healthscope Commercial |
$259.00
|
| Rate for Payer: Healthscope Whirlpool |
$251.23
|
| Rate for Payer: Humana Choice PPO Medicare |
$675.40
|
| Rate for Payer: Mclaren Commercial |
$233.10
|
| Rate for Payer: Mclaren Medicaid |
$362.01
|
| Rate for Payer: Mclaren Medicare |
$675.40
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$709.17
|
| Rate for Payer: Meridian Medicaid |
$380.12
|
| Rate for Payer: MI Amish Medical Board Commercial |
$776.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$220.15
|
| Rate for Payer: Nomi Health Commercial |
$212.38
|
| Rate for Payer: PACE Medicare |
$641.63
|
| Rate for Payer: PACE SWMI |
$675.40
|
| Rate for Payer: PHP Commercial |
$742.94
|
| Rate for Payer: PHP Medicaid |
$362.01
|
| Rate for Payer: PHP Medicare Advantage |
$675.40
|
| Rate for Payer: Priority Health Choice Medicaid |
$362.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$168.35
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$226.94
|
| Rate for Payer: Priority Health Medicare |
$675.40
|
| Rate for Payer: Priority Health Narrow Network |
$181.56
|
| Rate for Payer: Railroad Medicare Medicare |
$675.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$227.92
|
| Rate for Payer: UHC Dual Complete DSNP |
$675.40
|
| Rate for Payer: UHC Exchange |
$1,046.87
|
| Rate for Payer: UHC Medicare Advantage |
$675.40
|
| Rate for Payer: UHCCP DNSP |
$675.40
|
| Rate for Payer: UHCCP Medicaid |
$362.01
|
| Rate for Payer: VA VA |
$675.40
|
|
|
PR INJECTION AA&/STRD OTHER PERIPHERAL NERVE/BRANCH
|
Professional
|
Both
|
$259.00
|
|
|
Service Code
|
HCPCS 64450
|
| Min. Negotiated Rate |
$39.29 |
| Max. Negotiated Rate |
$168.35 |
| Rate for Payer: Aetna Commercial |
$52.65
|
| Rate for Payer: Aetna Medicare |
$39.29
|
| Rate for Payer: BCBS Complete |
$103.60
|
| Rate for Payer: BCBS MAPPO |
$39.29
|
| Rate for Payer: BCN Medicare Advantage |
$39.29
|
| Rate for Payer: Cash Price |
$207.20
|
| Rate for Payer: Cash Price |
$207.20
|
| Rate for Payer: Cofinity Commercial |
$56.58
|
| Rate for Payer: Cofinity Commercial |
$52.65
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$39.29
|
| Rate for Payer: Healthscope Commercial |
$47.15
|
| Rate for Payer: Healthscope Whirlpool |
$47.15
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$41.25
|
| Rate for Payer: Nomi Health Commercial |
$47.15
|
| Rate for Payer: PACE SWMI |
$39.29
|
| Rate for Payer: PHP Medicare Advantage |
$39.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$168.35
|
| Rate for Payer: Priority Health Medicare |
$39.29
|
| Rate for Payer: UHC Dual Complete DSNP |
$39.29
|
| Rate for Payer: UHC Medicare Advantage |
$39.29
|
| Rate for Payer: UHCCP DNSP |
$39.29
|
|
|
PR INJECTION AA&/STRD OTHER PERIPHERAL NERVE/BRANCH
|
Facility
|
IP
|
$259.00
|
|
|
Service Code
|
CPT 64450
|
| Hospital Charge Code |
64450
|
| Min. Negotiated Rate |
$168.35 |
| Max. Negotiated Rate |
$259.00 |
| Rate for Payer: Aetna Commercial |
$233.10
|
| Rate for Payer: ASR ASR |
$251.23
|
| Rate for Payer: ASR Commercial |
$251.23
|
| Rate for Payer: BCBS Trust/PPO |
$211.06
|
| Rate for Payer: BCN Commercial |
$200.80
|
| Rate for Payer: Cash Price |
$207.20
|
| Rate for Payer: Cofinity Commercial |
$243.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$207.20
|
| Rate for Payer: Healthscope Commercial |
$259.00
|
| Rate for Payer: Healthscope Whirlpool |
$251.23
|
| Rate for Payer: Mclaren Commercial |
$233.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$220.15
|
| Rate for Payer: Nomi Health Commercial |
$212.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$168.35
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$227.92
|
|
|
PR INJECTION AA&/STRD OTHER PERIPHERAL NERVE/BRANCH
|
Professional
|
Both
|
$259.00
|
|
|
Service Code
|
HCPCS 64450
|
| Hospital Charge Code |
64450
|
| Min. Negotiated Rate |
$39.29 |
| Max. Negotiated Rate |
$168.35 |
| Rate for Payer: Aetna Commercial |
$52.65
|
| Rate for Payer: Aetna Medicare |
$39.29
|
| Rate for Payer: BCBS Complete |
$103.60
|
| Rate for Payer: BCBS MAPPO |
$39.29
|
| Rate for Payer: BCN Medicare Advantage |
$39.29
|
| Rate for Payer: Cash Price |
$207.20
|
| Rate for Payer: Cash Price |
$207.20
|
| Rate for Payer: Cofinity Commercial |
$56.58
|
| Rate for Payer: Cofinity Commercial |
$52.65
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$39.29
|
| Rate for Payer: Healthscope Commercial |
$47.15
|
| Rate for Payer: Healthscope Whirlpool |
$47.15
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$41.25
|
| Rate for Payer: Nomi Health Commercial |
$47.15
|
| Rate for Payer: PACE SWMI |
$39.29
|
| Rate for Payer: PHP Medicare Advantage |
$39.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$168.35
|
| Rate for Payer: Priority Health Medicare |
$39.29
|
| Rate for Payer: UHC Dual Complete DSNP |
$39.29
|
| Rate for Payer: UHC Medicare Advantage |
$39.29
|
| Rate for Payer: UHCCP DNSP |
$39.29
|
|
|
PR INJECTION AA&/STRD PARACERVICAL NERVE
|
Professional
|
Both
|
$291.00
|
|
|
Service Code
|
HCPCS 64435
|
| Min. Negotiated Rate |
$41.86 |
| Max. Negotiated Rate |
$189.15 |
| Rate for Payer: Aetna Commercial |
$56.09
|
| Rate for Payer: Aetna Medicare |
$41.86
|
| Rate for Payer: BCBS Complete |
$116.40
|
| Rate for Payer: BCBS MAPPO |
$41.86
|
| Rate for Payer: BCN Medicare Advantage |
$41.86
|
| Rate for Payer: Cash Price |
$232.80
|
| Rate for Payer: Cash Price |
$232.80
|
| Rate for Payer: Cofinity Commercial |
$60.28
|
| Rate for Payer: Cofinity Commercial |
$56.09
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$41.86
|
| Rate for Payer: Healthscope Commercial |
$50.23
|
| Rate for Payer: Healthscope Whirlpool |
$50.23
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$43.95
|
| Rate for Payer: Nomi Health Commercial |
$50.23
|
| Rate for Payer: PACE SWMI |
$41.86
|
| Rate for Payer: PHP Medicare Advantage |
$41.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$189.15
|
| Rate for Payer: Priority Health Medicare |
$41.86
|
| Rate for Payer: UHC Dual Complete DSNP |
$41.86
|
| Rate for Payer: UHC Medicare Advantage |
$41.86
|
| Rate for Payer: UHCCP DNSP |
$41.86
|
|
|
PR INJECTION AA&/STRD PUDENDAL NERVE
|
Professional
|
Both
|
$255.00
|
|
|
Service Code
|
HCPCS 64430
|
| Min. Negotiated Rate |
$52.60 |
| Max. Negotiated Rate |
$165.75 |
| Rate for Payer: Aetna Commercial |
$70.48
|
| Rate for Payer: Aetna Medicare |
$52.60
|
| Rate for Payer: BCBS Complete |
$102.00
|
| Rate for Payer: BCBS MAPPO |
$52.60
|
| Rate for Payer: BCN Medicare Advantage |
$52.60
|
| Rate for Payer: Cash Price |
$204.00
|
| Rate for Payer: Cash Price |
$204.00
|
| Rate for Payer: Cofinity Commercial |
$75.74
|
| Rate for Payer: Cofinity Commercial |
$70.48
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$52.60
|
| Rate for Payer: Healthscope Commercial |
$63.12
|
| Rate for Payer: Healthscope Whirlpool |
$63.12
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$55.23
|
| Rate for Payer: Nomi Health Commercial |
$63.12
|
| Rate for Payer: PACE SWMI |
$52.60
|
| Rate for Payer: PHP Medicare Advantage |
$52.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$165.75
|
| Rate for Payer: Priority Health Medicare |
$52.60
|
| Rate for Payer: UHC Dual Complete DSNP |
$52.60
|
| Rate for Payer: UHC Medicare Advantage |
$52.60
|
| Rate for Payer: UHCCP DNSP |
$52.60
|
|
|
PR INJECTION AA&/STRD SCIATIC NERVE W/IMG GDN
|
Professional
|
Both
|
$271.00
|
|
|
Service Code
|
HCPCS 64445
|
| Min. Negotiated Rate |
$69.01 |
| Max. Negotiated Rate |
$176.15 |
| Rate for Payer: Aetna Commercial |
$92.47
|
| Rate for Payer: Aetna Medicare |
$69.01
|
| Rate for Payer: BCBS Complete |
$108.40
|
| Rate for Payer: BCBS MAPPO |
$69.01
|
| Rate for Payer: BCN Medicare Advantage |
$69.01
|
| Rate for Payer: Cash Price |
$216.80
|
| Rate for Payer: Cash Price |
$216.80
|
| Rate for Payer: Cofinity Commercial |
$99.37
|
| Rate for Payer: Cofinity Commercial |
$92.47
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$69.01
|
| Rate for Payer: Healthscope Commercial |
$82.81
|
| Rate for Payer: Healthscope Whirlpool |
$82.81
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$72.46
|
| Rate for Payer: Nomi Health Commercial |
$82.81
|
| Rate for Payer: PACE SWMI |
$69.01
|
| Rate for Payer: PHP Medicare Advantage |
$69.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$176.15
|
| Rate for Payer: Priority Health Medicare |
$69.01
|
| Rate for Payer: UHC Dual Complete DSNP |
$69.01
|
| Rate for Payer: UHC Medicare Advantage |
$69.01
|
| Rate for Payer: UHCCP DNSP |
$69.01
|
|
