|
HC DRESSING POLYWIC 3X3 SILVER
|
Facility
|
IP
|
$47.29
|
|
|
Service Code
|
CPT A6215
|
| Hospital Charge Code |
41601881
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$35.47 |
| Max. Negotiated Rate |
$43.98 |
| Rate for Payer: Aetna Commercial |
$40.86
|
| Rate for Payer: Cash Price |
$28.37
|
| Rate for Payer: Cigna All Commercial |
$40.81
|
| Rate for Payer: CORVEL All Commercial |
$43.98
|
| Rate for Payer: Coventry All Commercial |
$41.62
|
| Rate for Payer: Encore All Commercial |
$43.53
|
| Rate for Payer: Frontpath All Commercial |
$43.51
|
| Rate for Payer: Humana ChoiceCare |
$40.84
|
| Rate for Payer: Lutheran Preferred All Commercial |
$42.56
|
| Rate for Payer: PHCS All Commercial |
$35.47
|
| Rate for Payer: PHP All Commercial |
$35.86
|
| Rate for Payer: Sagamore Health Network All Products |
$36.51
|
| Rate for Payer: Signature Care EPO |
$39.25
|
| Rate for Payer: Signature Care PPO |
$41.62
|
| Rate for Payer: United Healthcare Commercial |
$37.26
|
|
|
HC DRESSING XEROFORM 2X2
|
Facility
|
IP
|
$3.66
|
|
| Hospital Charge Code |
41601043
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2.75 |
| Max. Negotiated Rate |
$3.40 |
| Rate for Payer: Aetna Commercial |
$3.16
|
| Rate for Payer: Cash Price |
$2.20
|
| Rate for Payer: Cigna All Commercial |
$3.16
|
| Rate for Payer: CORVEL All Commercial |
$3.40
|
| Rate for Payer: Coventry All Commercial |
$3.22
|
| Rate for Payer: Encore All Commercial |
$3.37
|
| Rate for Payer: Frontpath All Commercial |
$3.37
|
| Rate for Payer: Humana ChoiceCare |
$3.16
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.29
|
| Rate for Payer: PHCS All Commercial |
$2.75
|
| Rate for Payer: PHP All Commercial |
$2.78
|
| Rate for Payer: Sagamore Health Network All Products |
$2.83
|
| Rate for Payer: Signature Care EPO |
$3.04
|
| Rate for Payer: Signature Care PPO |
$3.22
|
| Rate for Payer: United Healthcare Commercial |
$2.88
|
|
|
HC DRESSING XEROFORM 2X2
|
Facility
|
OP
|
$3.66
|
|
| Hospital Charge Code |
41601043
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1.13 |
| Max. Negotiated Rate |
$31.20 |
| Rate for Payer: Aetna Commercial |
$3.09
|
| Rate for Payer: Aetna Medicare |
$1.17
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$31.20
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.13
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$2.10
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.29
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$31.20
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.35
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.29
|
| Rate for Payer: Cash Price |
$2.20
|
| Rate for Payer: Cash Price |
$2.20
|
| Rate for Payer: Centivo All Commercial |
$1.99
|
| Rate for Payer: Cigna All Commercial |
$3.16
|
| Rate for Payer: CORVEL All Commercial |
$3.40
|
| Rate for Payer: Coventry All Commercial |
$3.22
|
| Rate for Payer: Encore All Commercial |
$3.37
|
| Rate for Payer: Frontpath All Commercial |
$3.37
|
| Rate for Payer: Humana ChoiceCare |
$3.16
|
| Rate for Payer: Humana Medicare |
$1.17
|
| Rate for Payer: Lucent All Commercial |
$1.99
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.29
|
| Rate for Payer: Managed Health Services Medicaid |
$31.20
|
| Rate for Payer: MDWise Medicaid |
$31.20
|
| Rate for Payer: PHCS All Commercial |
$2.75
|
| Rate for Payer: PHP All Commercial |
$2.78
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.43
|
| Rate for Payer: Sagamore Health Network All Products |
$2.83
|
| Rate for Payer: Signature Care EPO |
$3.04
|
| Rate for Payer: Signature Care PPO |
$3.22
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3.11
|
| Rate for Payer: United Healthcare Commercial |
$2.88
|
| Rate for Payer: United Healthcare Medicare |
$1.17
|
|
|
HC DRUG ABUSE SCREEN 10 - URINE RANDOM
|
Facility
|
OP
|
$186.89
|
|
|
Service Code
|
CPT 80307
|
| Hospital Charge Code |
63001390
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$57.94 |
| Max. Negotiated Rate |
$173.81 |
| Rate for Payer: Aetna Commercial |
$157.74
|
| Rate for Payer: Aetna Medicare |
$59.80
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$62.14
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$57.94
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$85.89
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$85.89
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$62.14
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$68.78
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$65.79
|
| Rate for Payer: Cash Price |
$112.13
|
| Rate for Payer: Cash Price |
$112.13
|
| Rate for Payer: Centivo All Commercial |
$101.67
|
| Rate for Payer: Cigna All Commercial |
$161.29
|
| Rate for Payer: CORVEL All Commercial |
$173.81
|
| Rate for Payer: Coventry All Commercial |
$164.46
|
| Rate for Payer: Encore All Commercial |
$172.03
|
| Rate for Payer: Frontpath All Commercial |
$171.94
|
| Rate for Payer: Humana ChoiceCare |
$161.42
|
| Rate for Payer: Humana Medicare |
$59.80
|
| Rate for Payer: Lucent All Commercial |
$101.67
|
| Rate for Payer: Lutheran Preferred All Commercial |
$168.20
|
| Rate for Payer: Managed Health Services Medicaid |
$62.14
|
| Rate for Payer: MDWise Medicaid |
$62.14
|
| Rate for Payer: PHCS All Commercial |
$140.17
|
| Rate for Payer: PHP All Commercial |
$141.74
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$72.89
|
| Rate for Payer: Sagamore Health Network All Products |
$144.28
|
| Rate for Payer: Signature Care EPO |
$155.12
|
| Rate for Payer: Signature Care PPO |
$164.46
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$158.86
|
| Rate for Payer: United Healthcare Commercial |
$147.27
|
| Rate for Payer: United Healthcare Medicare |
$59.80
|
|
|
HC DRUG ABUSE SCREEN 10 - URINE RANDOM
|
Facility
|
IP
|
$186.89
|
|
|
Service Code
|
CPT 80307
|
| Hospital Charge Code |
63001390
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$140.17 |
| Max. Negotiated Rate |
$173.81 |
| Rate for Payer: Aetna Commercial |
$161.47
|
| Rate for Payer: Cash Price |
$112.13
|
| Rate for Payer: Cigna All Commercial |
$161.29
|
| Rate for Payer: CORVEL All Commercial |
$173.81
|
| Rate for Payer: Coventry All Commercial |
$164.46
|
| Rate for Payer: Encore All Commercial |
$172.03
|
| Rate for Payer: Frontpath All Commercial |
$171.94
|
| Rate for Payer: Humana ChoiceCare |
$161.42
|
| Rate for Payer: Lutheran Preferred All Commercial |
$168.20
|
| Rate for Payer: PHCS All Commercial |
$140.17
|
| Rate for Payer: PHP All Commercial |
$141.74
|
| Rate for Payer: Sagamore Health Network All Products |
$144.28
|
| Rate for Payer: Signature Care EPO |
$155.12
|
| Rate for Payer: Signature Care PPO |
$164.46
|
| Rate for Payer: United Healthcare Commercial |
$147.27
|
|
|
HC DRUG AEROSOL
|
Facility
|
IP
|
$169.33
|
|
|
Service Code
|
CPT 94640
|
| Hospital Charge Code |
1706479
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$127.00 |
| Max. Negotiated Rate |
$157.48 |
| Rate for Payer: Aetna Commercial |
$146.30
|
| Rate for Payer: Cash Price |
$101.60
|
| Rate for Payer: Cigna All Commercial |
$146.13
|
| Rate for Payer: CORVEL All Commercial |
$157.48
|
| Rate for Payer: Coventry All Commercial |
$149.01
|
| Rate for Payer: Encore All Commercial |
$155.87
|
| Rate for Payer: Frontpath All Commercial |
$155.78
|
| Rate for Payer: Humana ChoiceCare |
$146.25
|
| Rate for Payer: Lutheran Preferred All Commercial |
$152.40
|
| Rate for Payer: PHCS All Commercial |
$127.00
|
| Rate for Payer: PHP All Commercial |
$128.42
|
| Rate for Payer: Sagamore Health Network All Products |
$130.72
|
| Rate for Payer: Signature Care EPO |
$140.54
|
| Rate for Payer: Signature Care PPO |
$149.01
|
| Rate for Payer: United Healthcare Commercial |
$133.43
|
|
|
HC DRUG AEROSOL
|
Facility
|
OP
|
$169.33
|
|
|
Service Code
|
CPT 94640
|
| Hospital Charge Code |
1706479
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$6.37 |
| Max. Negotiated Rate |
$157.48 |
| Rate for Payer: Aetna Commercial |
$142.91
|
| Rate for Payer: Aetna Medicare |
$54.19
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$6.37
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$52.49
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$97.25
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$105.85
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$6.37
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$62.31
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$59.60
|
| Rate for Payer: Cash Price |
$101.60
|
| Rate for Payer: Cash Price |
$101.60
|
| Rate for Payer: Centivo All Commercial |
$92.12
|
| Rate for Payer: Cigna All Commercial |
$146.13
|
| Rate for Payer: CORVEL All Commercial |
$157.48
|
| Rate for Payer: Coventry All Commercial |
$149.01
|
| Rate for Payer: Encore All Commercial |
$155.87
|
| Rate for Payer: Frontpath All Commercial |
$155.78
|
| Rate for Payer: Humana ChoiceCare |
$146.25
|
| Rate for Payer: Humana Medicare |
$54.19
|
| Rate for Payer: Lucent All Commercial |
$92.12
|
| Rate for Payer: Lutheran Preferred All Commercial |
$152.40
|
| Rate for Payer: Managed Health Services Medicaid |
$6.37
|
| Rate for Payer: MDWise Medicaid |
$6.37
|
| Rate for Payer: PHCS All Commercial |
$127.00
|
| Rate for Payer: PHP All Commercial |
$128.42
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$66.04
|
| Rate for Payer: Sagamore Health Network All Products |
$130.72
|
| Rate for Payer: Signature Care EPO |
$140.54
|
| Rate for Payer: Signature Care PPO |
$149.01
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$143.93
|
| Rate for Payer: United Healthcare Commercial |
$133.43
|
| Rate for Payer: United Healthcare Medicare |
$54.19
|
|
|
HC DRUG SCREEN - NIDA
|
Facility
|
IP
|
$69.81
|
|
|
Service Code
|
CPT 80305
|
| Hospital Charge Code |
63001384
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$52.36 |
| Max. Negotiated Rate |
$64.92 |
| Rate for Payer: Aetna Commercial |
$60.32
|
| Rate for Payer: Cash Price |
$41.89
|
| Rate for Payer: Cigna All Commercial |
$60.25
|
| Rate for Payer: CORVEL All Commercial |
$64.92
|
| Rate for Payer: Coventry All Commercial |
$61.43
|
| Rate for Payer: Encore All Commercial |
$64.26
|
| Rate for Payer: Frontpath All Commercial |
$64.23
|
| Rate for Payer: Humana ChoiceCare |
$60.29
|
| Rate for Payer: Lutheran Preferred All Commercial |
$62.83
|
| Rate for Payer: PHCS All Commercial |
$52.36
|
| Rate for Payer: PHP All Commercial |
$52.94
|
| Rate for Payer: Sagamore Health Network All Products |
$53.89
|
| Rate for Payer: Signature Care EPO |
$57.94
|
| Rate for Payer: Signature Care PPO |
$61.43
|
| Rate for Payer: United Healthcare Commercial |
$55.01
|
|
|
HC DRUG SCREEN - NIDA
|
Facility
|
OP
|
$69.81
|
|
|
Service Code
|
CPT 80305
|
| Hospital Charge Code |
63001384
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.60 |
| Max. Negotiated Rate |
$64.92 |
| Rate for Payer: Aetna Commercial |
$58.92
|
| Rate for Payer: Aetna Medicare |
$22.34
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$12.60
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$21.64
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$32.08
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$32.08
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$12.60
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$25.69
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$24.57
|
| Rate for Payer: Cash Price |
$41.89
|
| Rate for Payer: Cash Price |
$41.89
|
| Rate for Payer: Centivo All Commercial |
$37.98
|
| Rate for Payer: Cigna All Commercial |
$60.25
|
| Rate for Payer: CORVEL All Commercial |
$64.92
|
| Rate for Payer: Coventry All Commercial |
$61.43
|
| Rate for Payer: Encore All Commercial |
$64.26
|
| Rate for Payer: Frontpath All Commercial |
$64.23
|
| Rate for Payer: Humana ChoiceCare |
$60.29
|
| Rate for Payer: Humana Medicare |
$22.34
|
| Rate for Payer: Lucent All Commercial |
$37.98
|
| Rate for Payer: Lutheran Preferred All Commercial |
$62.83
|
| Rate for Payer: Managed Health Services Medicaid |
$12.60
|
| Rate for Payer: MDWise Medicaid |
$12.60
|
| Rate for Payer: PHCS All Commercial |
$52.36
|
| Rate for Payer: PHP All Commercial |
$52.94
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$27.23
|
| Rate for Payer: Sagamore Health Network All Products |
$53.89
|
| Rate for Payer: Signature Care EPO |
$57.94
|
| Rate for Payer: Signature Care PPO |
$61.43
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$59.34
|
| Rate for Payer: United Healthcare Commercial |
$55.01
|
| Rate for Payer: United Healthcare Medicare |
$22.34
|
|
|
HC DRUG SCREEN - RAPID
|
Facility
|
OP
|
$81.35
|
|
|
Service Code
|
CPT 80305
|
| Hospital Charge Code |
63001318
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.60 |
| Max. Negotiated Rate |
$75.66 |
| Rate for Payer: Aetna Commercial |
$68.66
|
| Rate for Payer: Aetna Medicare |
$26.03
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$12.60
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$25.22
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$37.39
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$37.39
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$12.60
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$29.94
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$28.64
|
| Rate for Payer: Cash Price |
$48.81
|
| Rate for Payer: Cash Price |
$48.81
|
| Rate for Payer: Centivo All Commercial |
$44.25
|
| Rate for Payer: Cigna All Commercial |
$70.21
|
| Rate for Payer: CORVEL All Commercial |
$75.66
|
| Rate for Payer: Coventry All Commercial |
$71.59
|
| Rate for Payer: Encore All Commercial |
$74.88
|
| Rate for Payer: Frontpath All Commercial |
$74.84
|
| Rate for Payer: Humana ChoiceCare |
$70.26
|
| Rate for Payer: Humana Medicare |
$26.03
|
| Rate for Payer: Lucent All Commercial |
$44.25
|
| Rate for Payer: Lutheran Preferred All Commercial |
$73.22
|
| Rate for Payer: Managed Health Services Medicaid |
$12.60
|
| Rate for Payer: MDWise Medicaid |
$12.60
|
| Rate for Payer: PHCS All Commercial |
$61.01
|
| Rate for Payer: PHP All Commercial |
$61.70
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$31.73
|
| Rate for Payer: Sagamore Health Network All Products |
$62.80
|
| Rate for Payer: Signature Care EPO |
$67.52
|
| Rate for Payer: Signature Care PPO |
$71.59
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$69.15
|
| Rate for Payer: United Healthcare Commercial |
$64.10
|
| Rate for Payer: United Healthcare Medicare |
$26.03
|
|
|
HC DRUG SCREEN - RAPID
|
Facility
|
IP
|
$81.35
|
|
|
Service Code
|
CPT 80305
|
| Hospital Charge Code |
63001318
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$61.01 |
| Max. Negotiated Rate |
$75.66 |
| Rate for Payer: Aetna Commercial |
$70.29
|
| Rate for Payer: Cash Price |
$48.81
|
| Rate for Payer: Cigna All Commercial |
$70.21
|
| Rate for Payer: CORVEL All Commercial |
$75.66
|
| Rate for Payer: Coventry All Commercial |
$71.59
|
| Rate for Payer: Encore All Commercial |
$74.88
|
| Rate for Payer: Frontpath All Commercial |
$74.84
|
| Rate for Payer: Humana ChoiceCare |
$70.26
|
| Rate for Payer: Lutheran Preferred All Commercial |
$73.22
|
| Rate for Payer: PHCS All Commercial |
$61.01
|
| Rate for Payer: PHP All Commercial |
$61.70
|
| Rate for Payer: Sagamore Health Network All Products |
$62.80
|
| Rate for Payer: Signature Care EPO |
$67.52
|
| Rate for Payer: Signature Care PPO |
$71.59
|
| Rate for Payer: United Healthcare Commercial |
$64.10
|
|
|
HC DRUG SCREEN - STAT
|
Facility
|
OP
|
$404.28
|
|
|
Service Code
|
CPT 80305
|
| Hospital Charge Code |
63001385
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.60 |
| Max. Negotiated Rate |
$375.98 |
| Rate for Payer: Aetna Commercial |
$341.21
|
| Rate for Payer: Aetna Medicare |
$129.37
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$12.60
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$125.33
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$185.81
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$185.81
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$12.60
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$148.78
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$142.31
|
| Rate for Payer: Cash Price |
$242.57
|
| Rate for Payer: Cash Price |
$242.57
|
| Rate for Payer: Centivo All Commercial |
$219.93
|
| Rate for Payer: Cigna All Commercial |
$348.89
|
| Rate for Payer: CORVEL All Commercial |
$375.98
|
| Rate for Payer: Coventry All Commercial |
$355.77
|
| Rate for Payer: Encore All Commercial |
$372.14
|
| Rate for Payer: Frontpath All Commercial |
$371.94
|
| Rate for Payer: Humana ChoiceCare |
$349.18
|
| Rate for Payer: Humana Medicare |
$129.37
|
| Rate for Payer: Lucent All Commercial |
$219.93
|
| Rate for Payer: Lutheran Preferred All Commercial |
$363.85
|
| Rate for Payer: Managed Health Services Medicaid |
$12.60
|
| Rate for Payer: MDWise Medicaid |
$12.60
|
| Rate for Payer: PHCS All Commercial |
$303.21
|
| Rate for Payer: PHP All Commercial |
$306.61
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$157.67
|
| Rate for Payer: Sagamore Health Network All Products |
$312.10
|
| Rate for Payer: Signature Care EPO |
$335.55
|
| Rate for Payer: Signature Care PPO |
$355.77
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$343.64
|
| Rate for Payer: United Healthcare Commercial |
$318.57
|
| Rate for Payer: United Healthcare Medicare |
$129.37
|
|
|
HC DRUG SCREEN - STAT
|
Facility
|
IP
|
$404.28
|
|
|
Service Code
|
CPT 80305
|
| Hospital Charge Code |
63001385
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$303.21 |
| Max. Negotiated Rate |
$375.98 |
| Rate for Payer: Aetna Commercial |
$349.30
|
| Rate for Payer: Cash Price |
$242.57
|
| Rate for Payer: Cigna All Commercial |
$348.89
|
| Rate for Payer: CORVEL All Commercial |
$375.98
|
| Rate for Payer: Coventry All Commercial |
$355.77
|
| Rate for Payer: Encore All Commercial |
$372.14
|
| Rate for Payer: Frontpath All Commercial |
$371.94
|
| Rate for Payer: Humana ChoiceCare |
$349.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$363.85
|
| Rate for Payer: PHCS All Commercial |
$303.21
|
| Rate for Payer: PHP All Commercial |
$306.61
|
| Rate for Payer: Sagamore Health Network All Products |
$312.10
|
| Rate for Payer: Signature Care EPO |
$335.55
|
| Rate for Payer: Signature Care PPO |
$355.77
|
| Rate for Payer: United Healthcare Commercial |
$318.57
|
|
|
HC DRUG SCREEN - URINE
|
Facility
|
OP
|
$186.89
|
|
|
Service Code
|
CPT 80307
|
| Hospital Charge Code |
63001391
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$57.94 |
| Max. Negotiated Rate |
$173.81 |
| Rate for Payer: Aetna Commercial |
$157.74
|
| Rate for Payer: Aetna Medicare |
$59.80
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$62.14
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$57.94
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$85.89
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$85.89
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$62.14
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$68.78
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$65.79
|
| Rate for Payer: Cash Price |
$112.13
|
| Rate for Payer: Cash Price |
$112.13
|
| Rate for Payer: Centivo All Commercial |
$101.67
|
| Rate for Payer: Cigna All Commercial |
$161.29
|
| Rate for Payer: CORVEL All Commercial |
$173.81
|
| Rate for Payer: Coventry All Commercial |
$164.46
|
| Rate for Payer: Encore All Commercial |
$172.03
|
| Rate for Payer: Frontpath All Commercial |
$171.94
|
| Rate for Payer: Humana ChoiceCare |
$161.42
|
| Rate for Payer: Humana Medicare |
$59.80
|
| Rate for Payer: Lucent All Commercial |
$101.67
|
| Rate for Payer: Lutheran Preferred All Commercial |
$168.20
|
| Rate for Payer: Managed Health Services Medicaid |
$62.14
|
| Rate for Payer: MDWise Medicaid |
$62.14
|
| Rate for Payer: PHCS All Commercial |
$140.17
|
| Rate for Payer: PHP All Commercial |
$141.74
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$72.89
|
| Rate for Payer: Sagamore Health Network All Products |
$144.28
|
| Rate for Payer: Signature Care EPO |
$155.12
|
| Rate for Payer: Signature Care PPO |
$164.46
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$158.86
|
| Rate for Payer: United Healthcare Commercial |
$147.27
|
| Rate for Payer: United Healthcare Medicare |
$59.80
|
|
|
HC DRUG SCREEN - URINE
|
Facility
|
IP
|
$186.89
|
|
|
Service Code
|
CPT 80307
|
| Hospital Charge Code |
63001391
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$140.17 |
| Max. Negotiated Rate |
$173.81 |
| Rate for Payer: Aetna Commercial |
$161.47
|
| Rate for Payer: Cash Price |
$112.13
|
| Rate for Payer: Cigna All Commercial |
$161.29
|
| Rate for Payer: CORVEL All Commercial |
$173.81
|
| Rate for Payer: Coventry All Commercial |
$164.46
|
| Rate for Payer: Encore All Commercial |
$172.03
|
| Rate for Payer: Frontpath All Commercial |
$171.94
|
| Rate for Payer: Humana ChoiceCare |
$161.42
|
| Rate for Payer: Lutheran Preferred All Commercial |
$168.20
|
| Rate for Payer: PHCS All Commercial |
$140.17
|
| Rate for Payer: PHP All Commercial |
$141.74
|
| Rate for Payer: Sagamore Health Network All Products |
$144.28
|
| Rate for Payer: Signature Care EPO |
$155.12
|
| Rate for Payer: Signature Care PPO |
$164.46
|
| Rate for Payer: United Healthcare Commercial |
$147.27
|
|
|
HC DRY NEEDLE INSJ W/O NJX 1 OR 2 MUSC
|
Facility
|
OP
|
$10.20
|
|
|
Service Code
|
CPT 20560 GP
|
| Hospital Charge Code |
1720560
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$3.16 |
| Max. Negotiated Rate |
$47.81 |
| Rate for Payer: Aetna Commercial |
$8.61
|
| Rate for Payer: Aetna Medicare |
$3.26
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$47.81
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$3.16
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$5.86
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$6.38
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$47.81
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$3.75
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$3.59
|
| Rate for Payer: Cash Price |
$6.12
|
| Rate for Payer: Cash Price |
$6.12
|
| Rate for Payer: Centivo All Commercial |
$5.55
|
| Rate for Payer: Cigna All Commercial |
$8.80
|
| Rate for Payer: CORVEL All Commercial |
$9.49
|
| Rate for Payer: Coventry All Commercial |
$8.98
|
| Rate for Payer: Encore All Commercial |
$9.39
|
| Rate for Payer: Frontpath All Commercial |
$9.38
|
| Rate for Payer: Humana ChoiceCare |
$8.81
|
| Rate for Payer: Humana Medicare |
$3.26
|
| Rate for Payer: Lucent All Commercial |
$5.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$9.18
|
| Rate for Payer: Managed Health Services Medicaid |
$47.81
|
| Rate for Payer: MDWise Medicaid |
$47.81
|
| Rate for Payer: PHCS All Commercial |
$7.65
|
| Rate for Payer: PHP All Commercial |
$7.74
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$3.98
|
| Rate for Payer: Sagamore Health Network All Products |
$7.87
|
| Rate for Payer: Signature Care EPO |
$8.47
|
| Rate for Payer: Signature Care PPO |
$8.98
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$8.67
|
| Rate for Payer: United Healthcare Commercial |
$8.04
|
| Rate for Payer: United Healthcare Medicare |
$3.26
|
|
|
HC DRY NEEDLE INSJ W/O NJX 1 OR 2 MUSC
|
Facility
|
IP
|
$10.20
|
|
|
Service Code
|
CPT 20560 GP
|
| Hospital Charge Code |
1720560
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$7.65 |
| Max. Negotiated Rate |
$9.49 |
| Rate for Payer: Aetna Commercial |
$8.81
|
| Rate for Payer: Cash Price |
$6.12
|
| Rate for Payer: Cigna All Commercial |
$8.80
|
| Rate for Payer: CORVEL All Commercial |
$9.49
|
| Rate for Payer: Coventry All Commercial |
$8.98
|
| Rate for Payer: Encore All Commercial |
$9.39
|
| Rate for Payer: Frontpath All Commercial |
$9.38
|
| Rate for Payer: Humana ChoiceCare |
$8.81
|
| Rate for Payer: Lutheran Preferred All Commercial |
$9.18
|
| Rate for Payer: PHCS All Commercial |
$7.65
|
| Rate for Payer: PHP All Commercial |
$7.74
|
| Rate for Payer: Sagamore Health Network All Products |
$7.87
|
| Rate for Payer: Signature Care EPO |
$8.47
|
| Rate for Payer: Signature Care PPO |
$8.98
|
| Rate for Payer: United Healthcare Commercial |
$8.04
|
|
|
HC DRY NEEDLE INSJ W/O NJX 3+ MUSC
|
Facility
|
OP
|
$10.20
|
|
|
Service Code
|
CPT 20561 GP
|
| Hospital Charge Code |
1720561
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$3.16 |
| Max. Negotiated Rate |
$47.81 |
| Rate for Payer: Aetna Commercial |
$8.61
|
| Rate for Payer: Aetna Medicare |
$3.26
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$47.81
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$3.16
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$5.86
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$6.38
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$47.81
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$3.75
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$3.59
|
| Rate for Payer: Cash Price |
$6.12
|
| Rate for Payer: Cash Price |
$6.12
|
| Rate for Payer: Centivo All Commercial |
$5.55
|
| Rate for Payer: Cigna All Commercial |
$8.80
|
| Rate for Payer: CORVEL All Commercial |
$9.49
|
| Rate for Payer: Coventry All Commercial |
$8.98
|
| Rate for Payer: Encore All Commercial |
$9.39
|
| Rate for Payer: Frontpath All Commercial |
$9.38
|
| Rate for Payer: Humana ChoiceCare |
$8.81
|
| Rate for Payer: Humana Medicare |
$3.26
|
| Rate for Payer: Lucent All Commercial |
$5.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$9.18
|
| Rate for Payer: Managed Health Services Medicaid |
$47.81
|
| Rate for Payer: MDWise Medicaid |
$47.81
|
| Rate for Payer: PHCS All Commercial |
$7.65
|
| Rate for Payer: PHP All Commercial |
$7.74
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$3.98
|
| Rate for Payer: Sagamore Health Network All Products |
$7.87
|
| Rate for Payer: Signature Care EPO |
$8.47
|
| Rate for Payer: Signature Care PPO |
$8.98
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$8.67
|
| Rate for Payer: United Healthcare Commercial |
$8.04
|
| Rate for Payer: United Healthcare Medicare |
$3.26
|
|
|
HC DRY NEEDLE INSJ W/O NJX 3+ MUSC
|
Facility
|
IP
|
$10.20
|
|
|
Service Code
|
CPT 20561 GP
|
| Hospital Charge Code |
1720561
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$7.65 |
| Max. Negotiated Rate |
$9.49 |
| Rate for Payer: Aetna Commercial |
$8.81
|
| Rate for Payer: Cash Price |
$6.12
|
| Rate for Payer: Cigna All Commercial |
$8.80
|
| Rate for Payer: CORVEL All Commercial |
$9.49
|
| Rate for Payer: Coventry All Commercial |
$8.98
|
| Rate for Payer: Encore All Commercial |
$9.39
|
| Rate for Payer: Frontpath All Commercial |
$9.38
|
| Rate for Payer: Humana ChoiceCare |
$8.81
|
| Rate for Payer: Lutheran Preferred All Commercial |
$9.18
|
| Rate for Payer: PHCS All Commercial |
$7.65
|
| Rate for Payer: PHP All Commercial |
$7.74
|
| Rate for Payer: Sagamore Health Network All Products |
$7.87
|
| Rate for Payer: Signature Care EPO |
$8.47
|
| Rate for Payer: Signature Care PPO |
$8.98
|
| Rate for Payer: United Healthcare Commercial |
$8.04
|
|
|
HC DS ANAT OFFSET TP ADAPTER
|
Facility
|
IP
|
$3,600.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
41608531
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,700.00 |
| Max. Negotiated Rate |
$3,348.00 |
| Rate for Payer: Aetna Commercial |
$3,110.40
|
| Rate for Payer: Cash Price |
$2,160.00
|
| Rate for Payer: Cigna All Commercial |
$3,106.80
|
| Rate for Payer: CORVEL All Commercial |
$3,348.00
|
| Rate for Payer: Coventry All Commercial |
$3,168.00
|
| Rate for Payer: Encore All Commercial |
$3,313.80
|
| Rate for Payer: Frontpath All Commercial |
$3,312.00
|
| Rate for Payer: Humana ChoiceCare |
$3,109.32
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3,240.00
|
| Rate for Payer: PHCS All Commercial |
$2,700.00
|
| Rate for Payer: PHP All Commercial |
$2,730.24
|
| Rate for Payer: Sagamore Health Network All Products |
$2,779.20
|
| Rate for Payer: Signature Care EPO |
$2,988.00
|
| Rate for Payer: Signature Care PPO |
$3,168.00
|
| Rate for Payer: United Healthcare Commercial |
$2,836.80
|
|
|
HC DS ANAT OFFSET TP ADAPTER
|
Facility
|
OP
|
$3,600.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
41608531
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.40 |
| Max. Negotiated Rate |
$3,348.00 |
| Rate for Payer: Aetna Commercial |
$3,038.40
|
| Rate for Payer: Aetna Medicare |
$1,152.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$134.40
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1,116.00
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$2,067.48
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2,250.36
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$134.40
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1,324.80
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1,267.20
|
| Rate for Payer: Cash Price |
$2,160.00
|
| Rate for Payer: Cash Price |
$2,160.00
|
| Rate for Payer: Centivo All Commercial |
$1,958.40
|
| Rate for Payer: Cigna All Commercial |
$3,106.80
|
| Rate for Payer: CORVEL All Commercial |
$3,348.00
|
| Rate for Payer: Coventry All Commercial |
$3,168.00
|
| Rate for Payer: Encore All Commercial |
$3,313.80
|
| Rate for Payer: Frontpath All Commercial |
$3,312.00
|
| Rate for Payer: Humana ChoiceCare |
$3,109.32
|
| Rate for Payer: Humana Medicare |
$1,152.00
|
| Rate for Payer: Lucent All Commercial |
$1,958.40
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3,240.00
|
| Rate for Payer: Managed Health Services Medicaid |
$134.40
|
| Rate for Payer: MDWise Medicaid |
$134.40
|
| Rate for Payer: PHCS All Commercial |
$2,700.00
|
| Rate for Payer: PHP All Commercial |
$2,730.24
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1,404.00
|
| Rate for Payer: Sagamore Health Network All Products |
$2,779.20
|
| Rate for Payer: Signature Care EPO |
$2,988.00
|
| Rate for Payer: Signature Care PPO |
$3,168.00
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3,060.00
|
| Rate for Payer: United Healthcare Commercial |
$2,836.80
|
| Rate for Payer: United Healthcare Medicare |
$1,152.00
|
|
|
HC DS ATT FEM CR SZ 7 L
|
Facility
|
OP
|
$10,260.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
41608392
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.40 |
| Max. Negotiated Rate |
$9,541.80 |
| Rate for Payer: Aetna Commercial |
$8,659.44
|
| Rate for Payer: Aetna Medicare |
$3,283.20
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$134.40
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$3,180.60
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$5,892.32
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$6,413.53
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$134.40
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$3,775.68
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$3,611.52
|
| Rate for Payer: Cash Price |
$6,156.00
|
| Rate for Payer: Cash Price |
$6,156.00
|
| Rate for Payer: Centivo All Commercial |
$5,581.44
|
| Rate for Payer: Cigna All Commercial |
$8,854.38
|
| Rate for Payer: CORVEL All Commercial |
$9,541.80
|
| Rate for Payer: Coventry All Commercial |
$9,028.80
|
| Rate for Payer: Encore All Commercial |
$9,444.33
|
| Rate for Payer: Frontpath All Commercial |
$9,439.20
|
| Rate for Payer: Humana ChoiceCare |
$8,861.56
|
| Rate for Payer: Humana Medicare |
$3,283.20
|
| Rate for Payer: Lucent All Commercial |
$5,581.44
|
| Rate for Payer: Lutheran Preferred All Commercial |
$9,234.00
|
| Rate for Payer: Managed Health Services Medicaid |
$134.40
|
| Rate for Payer: MDWise Medicaid |
$134.40
|
| Rate for Payer: PHCS All Commercial |
$7,695.00
|
| Rate for Payer: PHP All Commercial |
$7,781.18
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$4,001.40
|
| Rate for Payer: Sagamore Health Network All Products |
$7,920.72
|
| Rate for Payer: Signature Care EPO |
$8,515.80
|
| Rate for Payer: Signature Care PPO |
$9,028.80
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$8,721.00
|
| Rate for Payer: United Healthcare Commercial |
$8,084.88
|
| Rate for Payer: United Healthcare Medicare |
$3,283.20
|
|
|
HC DS ATT FEM CR SZ 7 L
|
Facility
|
IP
|
$10,260.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
41608392
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,695.00 |
| Max. Negotiated Rate |
$9,541.80 |
| Rate for Payer: Aetna Commercial |
$8,864.64
|
| Rate for Payer: Cash Price |
$6,156.00
|
| Rate for Payer: Cigna All Commercial |
$8,854.38
|
| Rate for Payer: CORVEL All Commercial |
$9,541.80
|
| Rate for Payer: Coventry All Commercial |
$9,028.80
|
| Rate for Payer: Encore All Commercial |
$9,444.33
|
| Rate for Payer: Frontpath All Commercial |
$9,439.20
|
| Rate for Payer: Humana ChoiceCare |
$8,861.56
|
| Rate for Payer: Lutheran Preferred All Commercial |
$9,234.00
|
| Rate for Payer: PHCS All Commercial |
$7,695.00
|
| Rate for Payer: PHP All Commercial |
$7,781.18
|
| Rate for Payer: Sagamore Health Network All Products |
$7,920.72
|
| Rate for Payer: Signature Care EPO |
$8,515.80
|
| Rate for Payer: Signature Care PPO |
$9,028.80
|
| Rate for Payer: United Healthcare Commercial |
$8,084.88
|
|
|
HC DS ATT FEM NAR CR SZ 6 R
|
Facility
|
IP
|
$10,260.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
41608435
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,695.00 |
| Max. Negotiated Rate |
$9,541.80 |
| Rate for Payer: Aetna Commercial |
$8,864.64
|
| Rate for Payer: Cash Price |
$6,156.00
|
| Rate for Payer: Cigna All Commercial |
$8,854.38
|
| Rate for Payer: CORVEL All Commercial |
$9,541.80
|
| Rate for Payer: Coventry All Commercial |
$9,028.80
|
| Rate for Payer: Encore All Commercial |
$9,444.33
|
| Rate for Payer: Frontpath All Commercial |
$9,439.20
|
| Rate for Payer: Humana ChoiceCare |
$8,861.56
|
| Rate for Payer: Lutheran Preferred All Commercial |
$9,234.00
|
| Rate for Payer: PHCS All Commercial |
$7,695.00
|
| Rate for Payer: PHP All Commercial |
$7,781.18
|
| Rate for Payer: Sagamore Health Network All Products |
$7,920.72
|
| Rate for Payer: Signature Care EPO |
$8,515.80
|
| Rate for Payer: Signature Care PPO |
$9,028.80
|
| Rate for Payer: United Healthcare Commercial |
$8,084.88
|
|
|
HC DS ATT FEM NAR CR SZ 6 R
|
Facility
|
OP
|
$10,260.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
41608435
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.40 |
| Max. Negotiated Rate |
$9,541.80 |
| Rate for Payer: Aetna Commercial |
$8,659.44
|
| Rate for Payer: Aetna Medicare |
$3,283.20
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$134.40
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$3,180.60
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$5,892.32
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$6,413.53
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$134.40
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$3,775.68
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$3,611.52
|
| Rate for Payer: Cash Price |
$6,156.00
|
| Rate for Payer: Cash Price |
$6,156.00
|
| Rate for Payer: Centivo All Commercial |
$5,581.44
|
| Rate for Payer: Cigna All Commercial |
$8,854.38
|
| Rate for Payer: CORVEL All Commercial |
$9,541.80
|
| Rate for Payer: Coventry All Commercial |
$9,028.80
|
| Rate for Payer: Encore All Commercial |
$9,444.33
|
| Rate for Payer: Frontpath All Commercial |
$9,439.20
|
| Rate for Payer: Humana ChoiceCare |
$8,861.56
|
| Rate for Payer: Humana Medicare |
$3,283.20
|
| Rate for Payer: Lucent All Commercial |
$5,581.44
|
| Rate for Payer: Lutheran Preferred All Commercial |
$9,234.00
|
| Rate for Payer: Managed Health Services Medicaid |
$134.40
|
| Rate for Payer: MDWise Medicaid |
$134.40
|
| Rate for Payer: PHCS All Commercial |
$7,695.00
|
| Rate for Payer: PHP All Commercial |
$7,781.18
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$4,001.40
|
| Rate for Payer: Sagamore Health Network All Products |
$7,920.72
|
| Rate for Payer: Signature Care EPO |
$8,515.80
|
| Rate for Payer: Signature Care PPO |
$9,028.80
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$8,721.00
|
| Rate for Payer: United Healthcare Commercial |
$8,084.88
|
| Rate for Payer: United Healthcare Medicare |
$3,283.20
|
|
