|
HC FLUIDOTHERAPY-PT
|
Facility
|
IP
|
$115.06
|
|
|
Service Code
|
CPT 97022 GP
|
| Hospital Charge Code |
1728033
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$86.30 |
| Max. Negotiated Rate |
$107.01 |
| Rate for Payer: Aetna Commercial |
$99.41
|
| Rate for Payer: Cash Price |
$69.04
|
| Rate for Payer: Cigna All Commercial |
$99.30
|
| Rate for Payer: CORVEL All Commercial |
$107.01
|
| Rate for Payer: Coventry All Commercial |
$101.25
|
| Rate for Payer: Encore All Commercial |
$105.91
|
| Rate for Payer: Frontpath All Commercial |
$105.86
|
| Rate for Payer: Humana ChoiceCare |
$99.38
|
| Rate for Payer: Lutheran Preferred All Commercial |
$103.55
|
| Rate for Payer: PHCS All Commercial |
$86.30
|
| Rate for Payer: PHP All Commercial |
$87.26
|
| Rate for Payer: Sagamore Health Network All Products |
$88.83
|
| Rate for Payer: Signature Care EPO |
$95.50
|
| Rate for Payer: Signature Care PPO |
$101.25
|
| Rate for Payer: United Healthcare Commercial |
$90.67
|
|
|
HC FLUIDOTHERAPY-PT
|
Facility
|
OP
|
$115.06
|
|
|
Service Code
|
CPT 97022 GP
|
| Hospital Charge Code |
1728033
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$35.67 |
| Max. Negotiated Rate |
$107.01 |
| Rate for Payer: Aetna Commercial |
$97.11
|
| Rate for Payer: Aetna Medicare |
$36.82
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$47.81
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$35.67
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$66.08
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$71.92
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$47.81
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$42.34
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$40.50
|
| Rate for Payer: Cash Price |
$69.04
|
| Rate for Payer: Cash Price |
$69.04
|
| Rate for Payer: Centivo All Commercial |
$62.59
|
| Rate for Payer: Cigna All Commercial |
$99.30
|
| Rate for Payer: CORVEL All Commercial |
$107.01
|
| Rate for Payer: Coventry All Commercial |
$101.25
|
| Rate for Payer: Encore All Commercial |
$105.91
|
| Rate for Payer: Frontpath All Commercial |
$105.86
|
| Rate for Payer: Humana ChoiceCare |
$99.38
|
| Rate for Payer: Humana Medicare |
$36.82
|
| Rate for Payer: Lucent All Commercial |
$62.59
|
| Rate for Payer: Lutheran Preferred All Commercial |
$103.55
|
| Rate for Payer: Managed Health Services Medicaid |
$47.81
|
| Rate for Payer: MDWise Medicaid |
$47.81
|
| Rate for Payer: PHCS All Commercial |
$86.30
|
| Rate for Payer: PHP All Commercial |
$87.26
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$44.87
|
| Rate for Payer: Sagamore Health Network All Products |
$88.83
|
| Rate for Payer: Signature Care EPO |
$95.50
|
| Rate for Payer: Signature Care PPO |
$101.25
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$97.80
|
| Rate for Payer: United Healthcare Commercial |
$90.67
|
| Rate for Payer: United Healthcare Medicare |
$36.82
|
|
|
HC FLUORES AB SCREEN-EA
|
Facility
|
IP
|
$157.06
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
63001888
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$117.80 |
| Max. Negotiated Rate |
$146.07 |
| Rate for Payer: Aetna Commercial |
$135.70
|
| Rate for Payer: Cash Price |
$94.24
|
| Rate for Payer: Cigna All Commercial |
$135.54
|
| Rate for Payer: CORVEL All Commercial |
$146.07
|
| Rate for Payer: Coventry All Commercial |
$138.21
|
| Rate for Payer: Encore All Commercial |
$144.57
|
| Rate for Payer: Frontpath All Commercial |
$144.50
|
| Rate for Payer: Humana ChoiceCare |
$135.65
|
| Rate for Payer: Lutheran Preferred All Commercial |
$141.35
|
| Rate for Payer: PHCS All Commercial |
$117.80
|
| Rate for Payer: PHP All Commercial |
$119.11
|
| Rate for Payer: Sagamore Health Network All Products |
$121.25
|
| Rate for Payer: Signature Care EPO |
$130.36
|
| Rate for Payer: Signature Care PPO |
$138.21
|
| Rate for Payer: United Healthcare Commercial |
$123.76
|
|
|
HC FLUORES AB SCREEN-EA
|
Facility
|
OP
|
$157.06
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
63001888
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.05 |
| Max. Negotiated Rate |
$146.07 |
| Rate for Payer: Aetna Commercial |
$132.56
|
| Rate for Payer: Aetna Medicare |
$50.26
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$12.05
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$48.69
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$72.18
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$72.18
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$12.05
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$57.80
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$55.29
|
| Rate for Payer: Cash Price |
$94.24
|
| Rate for Payer: Cash Price |
$94.24
|
| Rate for Payer: Centivo All Commercial |
$85.44
|
| Rate for Payer: Cigna All Commercial |
$135.54
|
| Rate for Payer: CORVEL All Commercial |
$146.07
|
| Rate for Payer: Coventry All Commercial |
$138.21
|
| Rate for Payer: Encore All Commercial |
$144.57
|
| Rate for Payer: Frontpath All Commercial |
$144.50
|
| Rate for Payer: Humana ChoiceCare |
$135.65
|
| Rate for Payer: Humana Medicare |
$50.26
|
| Rate for Payer: Lucent All Commercial |
$85.44
|
| Rate for Payer: Lutheran Preferred All Commercial |
$141.35
|
| Rate for Payer: Managed Health Services Medicaid |
$12.05
|
| Rate for Payer: MDWise Medicaid |
$12.05
|
| Rate for Payer: PHCS All Commercial |
$117.80
|
| Rate for Payer: PHP All Commercial |
$119.11
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$61.25
|
| Rate for Payer: Sagamore Health Network All Products |
$121.25
|
| Rate for Payer: Signature Care EPO |
$130.36
|
| Rate for Payer: Signature Care PPO |
$138.21
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$133.50
|
| Rate for Payer: United Healthcare Commercial |
$123.76
|
| Rate for Payer: United Healthcare Medicare |
$50.26
|
|
|
HC FLUORO GUIDANCE FOR NDL PLACE
|
Facility
|
IP
|
$874.54
|
|
|
Service Code
|
CPT 77002
|
| Hospital Charge Code |
1597600
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$655.90 |
| Max. Negotiated Rate |
$813.32 |
| Rate for Payer: Aetna Commercial |
$755.60
|
| Rate for Payer: Cash Price |
$524.72
|
| Rate for Payer: Cigna All Commercial |
$754.73
|
| Rate for Payer: CORVEL All Commercial |
$813.32
|
| Rate for Payer: Coventry All Commercial |
$769.60
|
| Rate for Payer: Encore All Commercial |
$805.01
|
| Rate for Payer: Frontpath All Commercial |
$804.58
|
| Rate for Payer: Humana ChoiceCare |
$755.34
|
| Rate for Payer: Lutheran Preferred All Commercial |
$787.09
|
| Rate for Payer: PHCS All Commercial |
$655.90
|
| Rate for Payer: PHP All Commercial |
$663.25
|
| Rate for Payer: Sagamore Health Network All Products |
$675.14
|
| Rate for Payer: Signature Care EPO |
$725.87
|
| Rate for Payer: Signature Care PPO |
$769.60
|
| Rate for Payer: United Healthcare Commercial |
$689.14
|
|
|
HC FLUORO GUIDANCE FOR NDL PLACE
|
Facility
|
OP
|
$874.54
|
|
|
Service Code
|
CPT 77002
|
| Hospital Charge Code |
1597600
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$51.69 |
| Max. Negotiated Rate |
$813.32 |
| Rate for Payer: Aetna Commercial |
$738.11
|
| Rate for Payer: Aetna Medicare |
$279.85
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$51.69
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$271.11
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$502.25
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$546.67
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$51.69
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$321.83
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$307.84
|
| Rate for Payer: Cash Price |
$524.72
|
| Rate for Payer: Cash Price |
$524.72
|
| Rate for Payer: Centivo All Commercial |
$475.75
|
| Rate for Payer: Cigna All Commercial |
$754.73
|
| Rate for Payer: CORVEL All Commercial |
$813.32
|
| Rate for Payer: Coventry All Commercial |
$769.60
|
| Rate for Payer: Encore All Commercial |
$805.01
|
| Rate for Payer: Frontpath All Commercial |
$804.58
|
| Rate for Payer: Humana ChoiceCare |
$755.34
|
| Rate for Payer: Humana Medicare |
$279.85
|
| Rate for Payer: Lucent All Commercial |
$475.75
|
| Rate for Payer: Lutheran Preferred All Commercial |
$787.09
|
| Rate for Payer: Managed Health Services Medicaid |
$51.69
|
| Rate for Payer: MDWise Medicaid |
$51.69
|
| Rate for Payer: PHCS All Commercial |
$655.90
|
| Rate for Payer: PHP All Commercial |
$663.25
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$341.07
|
| Rate for Payer: Sagamore Health Network All Products |
$675.14
|
| Rate for Payer: Signature Care EPO |
$725.87
|
| Rate for Payer: Signature Care PPO |
$769.60
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$743.36
|
| Rate for Payer: United Healthcare Commercial |
$689.14
|
| Rate for Payer: United Healthcare Medicare |
$279.85
|
|
|
HC FNA BX W/CT GDN 1ST LES
|
Facility
|
OP
|
$1,734.00
|
|
| Hospital Charge Code |
1660009
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$537.54 |
| Max. Negotiated Rate |
$1,612.62 |
| Rate for Payer: Aetna Commercial |
$1,463.50
|
| Rate for Payer: Aetna Medicare |
$554.88
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$537.54
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$995.84
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,083.92
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$638.11
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$610.37
|
| Rate for Payer: Cash Price |
$1,040.40
|
| Rate for Payer: Centivo All Commercial |
$943.30
|
| Rate for Payer: Cigna All Commercial |
$1,496.44
|
| Rate for Payer: CORVEL All Commercial |
$1,612.62
|
| Rate for Payer: Coventry All Commercial |
$1,525.92
|
| Rate for Payer: Encore All Commercial |
$1,596.15
|
| Rate for Payer: Frontpath All Commercial |
$1,595.28
|
| Rate for Payer: Humana ChoiceCare |
$1,497.66
|
| Rate for Payer: Humana Medicare |
$554.88
|
| Rate for Payer: Lucent All Commercial |
$943.30
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,560.60
|
| Rate for Payer: PHCS All Commercial |
$1,300.50
|
| Rate for Payer: PHP All Commercial |
$1,315.07
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$676.26
|
| Rate for Payer: Sagamore Health Network All Products |
$1,338.65
|
| Rate for Payer: Signature Care EPO |
$1,439.22
|
| Rate for Payer: Signature Care PPO |
$1,525.92
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,473.90
|
| Rate for Payer: United Healthcare Commercial |
$1,366.39
|
| Rate for Payer: United Healthcare Medicare |
$554.88
|
|
|
HC FNA BX W/CT GDN 1ST LES
|
Facility
|
IP
|
$1,734.00
|
|
| Hospital Charge Code |
1660009
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,300.50 |
| Max. Negotiated Rate |
$1,612.62 |
| Rate for Payer: Aetna Commercial |
$1,498.18
|
| Rate for Payer: Cash Price |
$1,040.40
|
| Rate for Payer: Cigna All Commercial |
$1,496.44
|
| Rate for Payer: CORVEL All Commercial |
$1,612.62
|
| Rate for Payer: Coventry All Commercial |
$1,525.92
|
| Rate for Payer: Encore All Commercial |
$1,596.15
|
| Rate for Payer: Frontpath All Commercial |
$1,595.28
|
| Rate for Payer: Humana ChoiceCare |
$1,497.66
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,560.60
|
| Rate for Payer: PHCS All Commercial |
$1,300.50
|
| Rate for Payer: PHP All Commercial |
$1,315.07
|
| Rate for Payer: Sagamore Health Network All Products |
$1,338.65
|
| Rate for Payer: Signature Care EPO |
$1,439.22
|
| Rate for Payer: Signature Care PPO |
$1,525.92
|
| Rate for Payer: United Healthcare Commercial |
$1,366.39
|
|
|
HC FNA BX W/US GDN 1ST LES
|
Facility
|
OP
|
$1,661.84
|
|
|
Service Code
|
CPT 10005
|
| Hospital Charge Code |
1640005
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$515.17 |
| Max. Negotiated Rate |
$1,545.51 |
| Rate for Payer: Aetna Commercial |
$1,402.59
|
| Rate for Payer: Aetna Medicare |
$531.79
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$582.98
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$515.17
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$954.39
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,038.82
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$582.98
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$611.56
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$584.97
|
| Rate for Payer: Cash Price |
$997.10
|
| Rate for Payer: Cash Price |
$997.10
|
| Rate for Payer: Centivo All Commercial |
$904.04
|
| Rate for Payer: Cigna All Commercial |
$1,434.17
|
| Rate for Payer: CORVEL All Commercial |
$1,545.51
|
| Rate for Payer: Coventry All Commercial |
$1,462.42
|
| Rate for Payer: Encore All Commercial |
$1,529.72
|
| Rate for Payer: Frontpath All Commercial |
$1,528.89
|
| Rate for Payer: Humana ChoiceCare |
$1,435.33
|
| Rate for Payer: Humana Medicare |
$531.79
|
| Rate for Payer: Lucent All Commercial |
$904.04
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,495.66
|
| Rate for Payer: Managed Health Services Medicaid |
$582.98
|
| Rate for Payer: MDWise Medicaid |
$582.98
|
| Rate for Payer: PHCS All Commercial |
$1,246.38
|
| Rate for Payer: PHP All Commercial |
$1,260.34
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$648.12
|
| Rate for Payer: Sagamore Health Network All Products |
$1,282.94
|
| Rate for Payer: Signature Care EPO |
$1,379.33
|
| Rate for Payer: Signature Care PPO |
$1,462.42
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,412.56
|
| Rate for Payer: United Healthcare Commercial |
$1,309.53
|
| Rate for Payer: United Healthcare Medicare |
$531.79
|
|
|
HC FNA BX W/US GDN 1ST LES
|
Facility
|
IP
|
$1,661.84
|
|
|
Service Code
|
CPT 10005
|
| Hospital Charge Code |
1640005
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,246.38 |
| Max. Negotiated Rate |
$1,545.51 |
| Rate for Payer: Aetna Commercial |
$1,435.83
|
| Rate for Payer: Cash Price |
$997.10
|
| Rate for Payer: Cigna All Commercial |
$1,434.17
|
| Rate for Payer: CORVEL All Commercial |
$1,545.51
|
| Rate for Payer: Coventry All Commercial |
$1,462.42
|
| Rate for Payer: Encore All Commercial |
$1,529.72
|
| Rate for Payer: Frontpath All Commercial |
$1,528.89
|
| Rate for Payer: Humana ChoiceCare |
$1,435.33
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,495.66
|
| Rate for Payer: PHCS All Commercial |
$1,246.38
|
| Rate for Payer: PHP All Commercial |
$1,260.34
|
| Rate for Payer: Sagamore Health Network All Products |
$1,282.94
|
| Rate for Payer: Signature Care EPO |
$1,379.33
|
| Rate for Payer: Signature Care PPO |
$1,462.42
|
| Rate for Payer: United Healthcare Commercial |
$1,309.53
|
|
|
HC FNA BX W/US GDN EA ADDL
|
Facility
|
OP
|
$1,081.71
|
|
|
Service Code
|
CPT 10006
|
| Hospital Charge Code |
1640006
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$335.33 |
| Max. Negotiated Rate |
$1,005.99 |
| Rate for Payer: Aetna Commercial |
$912.96
|
| Rate for Payer: Aetna Medicare |
$346.15
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$335.33
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$621.23
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$676.18
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$398.07
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$380.76
|
| Rate for Payer: Cash Price |
$649.03
|
| Rate for Payer: Centivo All Commercial |
$588.45
|
| Rate for Payer: Cigna All Commercial |
$933.52
|
| Rate for Payer: CORVEL All Commercial |
$1,005.99
|
| Rate for Payer: Coventry All Commercial |
$951.90
|
| Rate for Payer: Encore All Commercial |
$995.71
|
| Rate for Payer: Frontpath All Commercial |
$995.17
|
| Rate for Payer: Humana ChoiceCare |
$934.27
|
| Rate for Payer: Humana Medicare |
$346.15
|
| Rate for Payer: Lucent All Commercial |
$588.45
|
| Rate for Payer: Lutheran Preferred All Commercial |
$973.54
|
| Rate for Payer: PHCS All Commercial |
$811.28
|
| Rate for Payer: PHP All Commercial |
$820.37
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$421.87
|
| Rate for Payer: Sagamore Health Network All Products |
$835.08
|
| Rate for Payer: Signature Care EPO |
$897.82
|
| Rate for Payer: Signature Care PPO |
$951.90
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$919.45
|
| Rate for Payer: United Healthcare Commercial |
$852.39
|
| Rate for Payer: United Healthcare Medicare |
$346.15
|
|
|
HC FNA BX W/US GDN EA ADDL
|
Facility
|
IP
|
$1,081.71
|
|
|
Service Code
|
CPT 10006
|
| Hospital Charge Code |
1640006
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$811.28 |
| Max. Negotiated Rate |
$1,005.99 |
| Rate for Payer: Aetna Commercial |
$934.60
|
| Rate for Payer: Cash Price |
$649.03
|
| Rate for Payer: Cigna All Commercial |
$933.52
|
| Rate for Payer: CORVEL All Commercial |
$1,005.99
|
| Rate for Payer: Coventry All Commercial |
$951.90
|
| Rate for Payer: Encore All Commercial |
$995.71
|
| Rate for Payer: Frontpath All Commercial |
$995.17
|
| Rate for Payer: Humana ChoiceCare |
$934.27
|
| Rate for Payer: Lutheran Preferred All Commercial |
$973.54
|
| Rate for Payer: PHCS All Commercial |
$811.28
|
| Rate for Payer: PHP All Commercial |
$820.37
|
| Rate for Payer: Sagamore Health Network All Products |
$835.08
|
| Rate for Payer: Signature Care EPO |
$897.82
|
| Rate for Payer: Signature Care PPO |
$951.90
|
| Rate for Payer: United Healthcare Commercial |
$852.39
|
|
|
HC FOLATE LEVEL, RBC
|
Facility
|
IP
|
$209.44
|
|
|
Service Code
|
CPT 82747
|
| Hospital Charge Code |
63001158
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$157.08 |
| Max. Negotiated Rate |
$194.78 |
| Rate for Payer: Aetna Commercial |
$180.96
|
| Rate for Payer: Cash Price |
$125.66
|
| Rate for Payer: Cigna All Commercial |
$180.75
|
| Rate for Payer: CORVEL All Commercial |
$194.78
|
| Rate for Payer: Coventry All Commercial |
$184.31
|
| Rate for Payer: Encore All Commercial |
$192.79
|
| Rate for Payer: Frontpath All Commercial |
$192.68
|
| Rate for Payer: Humana ChoiceCare |
$180.89
|
| Rate for Payer: Lutheran Preferred All Commercial |
$188.50
|
| Rate for Payer: PHCS All Commercial |
$157.08
|
| Rate for Payer: PHP All Commercial |
$158.84
|
| Rate for Payer: Sagamore Health Network All Products |
$161.69
|
| Rate for Payer: Signature Care EPO |
$173.84
|
| Rate for Payer: Signature Care PPO |
$184.31
|
| Rate for Payer: United Healthcare Commercial |
$165.04
|
|
|
HC FOLATE LEVEL, RBC
|
Facility
|
OP
|
$209.44
|
|
|
Service Code
|
CPT 82747
|
| Hospital Charge Code |
63001158
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.65 |
| Max. Negotiated Rate |
$194.78 |
| Rate for Payer: Aetna Commercial |
$176.77
|
| Rate for Payer: Aetna Medicare |
$67.02
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$17.65
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$64.93
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$96.26
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$96.26
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$17.65
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$77.07
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$73.72
|
| Rate for Payer: Cash Price |
$125.66
|
| Rate for Payer: Cash Price |
$125.66
|
| Rate for Payer: Centivo All Commercial |
$113.94
|
| Rate for Payer: Cigna All Commercial |
$180.75
|
| Rate for Payer: CORVEL All Commercial |
$194.78
|
| Rate for Payer: Coventry All Commercial |
$184.31
|
| Rate for Payer: Encore All Commercial |
$192.79
|
| Rate for Payer: Frontpath All Commercial |
$192.68
|
| Rate for Payer: Humana ChoiceCare |
$180.89
|
| Rate for Payer: Humana Medicare |
$67.02
|
| Rate for Payer: Lucent All Commercial |
$113.94
|
| Rate for Payer: Lutheran Preferred All Commercial |
$188.50
|
| Rate for Payer: Managed Health Services Medicaid |
$17.65
|
| Rate for Payer: MDWise Medicaid |
$17.65
|
| Rate for Payer: PHCS All Commercial |
$157.08
|
| Rate for Payer: PHP All Commercial |
$158.84
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$81.68
|
| Rate for Payer: Sagamore Health Network All Products |
$161.69
|
| Rate for Payer: Signature Care EPO |
$173.84
|
| Rate for Payer: Signature Care PPO |
$184.31
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$178.02
|
| Rate for Payer: United Healthcare Commercial |
$165.04
|
| Rate for Payer: United Healthcare Medicare |
$67.02
|
|
|
HC FOLATE SERUM
|
Facility
|
OP
|
$199.81
|
|
|
Service Code
|
CPT 82746
|
| Hospital Charge Code |
63001157
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.70 |
| Max. Negotiated Rate |
$185.82 |
| Rate for Payer: Aetna Commercial |
$168.64
|
| Rate for Payer: Aetna Medicare |
$63.94
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$14.70
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$61.94
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$91.83
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$91.83
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$14.70
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$73.53
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$70.33
|
| Rate for Payer: Cash Price |
$119.89
|
| Rate for Payer: Cash Price |
$119.89
|
| Rate for Payer: Centivo All Commercial |
$108.70
|
| Rate for Payer: Cigna All Commercial |
$172.44
|
| Rate for Payer: CORVEL All Commercial |
$185.82
|
| Rate for Payer: Coventry All Commercial |
$175.83
|
| Rate for Payer: Encore All Commercial |
$183.93
|
| Rate for Payer: Frontpath All Commercial |
$183.83
|
| Rate for Payer: Humana ChoiceCare |
$172.58
|
| Rate for Payer: Humana Medicare |
$63.94
|
| Rate for Payer: Lucent All Commercial |
$108.70
|
| Rate for Payer: Lutheran Preferred All Commercial |
$179.83
|
| Rate for Payer: Managed Health Services Medicaid |
$14.70
|
| Rate for Payer: MDWise Medicaid |
$14.70
|
| Rate for Payer: PHCS All Commercial |
$149.86
|
| Rate for Payer: PHP All Commercial |
$151.54
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$77.93
|
| Rate for Payer: Sagamore Health Network All Products |
$154.25
|
| Rate for Payer: Signature Care EPO |
$165.84
|
| Rate for Payer: Signature Care PPO |
$175.83
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$169.84
|
| Rate for Payer: United Healthcare Commercial |
$157.45
|
| Rate for Payer: United Healthcare Medicare |
$63.94
|
|
|
HC FOLATE SERUM
|
Facility
|
IP
|
$199.81
|
|
|
Service Code
|
CPT 82746
|
| Hospital Charge Code |
63001157
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$149.86 |
| Max. Negotiated Rate |
$185.82 |
| Rate for Payer: Aetna Commercial |
$172.64
|
| Rate for Payer: Cash Price |
$119.89
|
| Rate for Payer: Cigna All Commercial |
$172.44
|
| Rate for Payer: CORVEL All Commercial |
$185.82
|
| Rate for Payer: Coventry All Commercial |
$175.83
|
| Rate for Payer: Encore All Commercial |
$183.93
|
| Rate for Payer: Frontpath All Commercial |
$183.83
|
| Rate for Payer: Humana ChoiceCare |
$172.58
|
| Rate for Payer: Lutheran Preferred All Commercial |
$179.83
|
| Rate for Payer: PHCS All Commercial |
$149.86
|
| Rate for Payer: PHP All Commercial |
$151.54
|
| Rate for Payer: Sagamore Health Network All Products |
$154.25
|
| Rate for Payer: Signature Care EPO |
$165.84
|
| Rate for Payer: Signature Care PPO |
$175.83
|
| Rate for Payer: United Healthcare Commercial |
$157.45
|
|
|
HC FREE T4
|
Facility
|
OP
|
$123.26
|
|
|
Service Code
|
CPT 84439
|
| Hospital Charge Code |
63001180
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$9.02 |
| Max. Negotiated Rate |
$114.63 |
| Rate for Payer: Aetna Commercial |
$104.03
|
| Rate for Payer: Aetna Medicare |
$39.44
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.02
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$38.21
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$56.65
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$56.65
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.02
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$45.36
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$43.39
|
| Rate for Payer: Cash Price |
$73.96
|
| Rate for Payer: Cash Price |
$73.96
|
| Rate for Payer: Centivo All Commercial |
$67.05
|
| Rate for Payer: Cigna All Commercial |
$106.37
|
| Rate for Payer: CORVEL All Commercial |
$114.63
|
| Rate for Payer: Coventry All Commercial |
$108.47
|
| Rate for Payer: Encore All Commercial |
$113.46
|
| Rate for Payer: Frontpath All Commercial |
$113.40
|
| Rate for Payer: Humana ChoiceCare |
$106.46
|
| Rate for Payer: Humana Medicare |
$39.44
|
| Rate for Payer: Lucent All Commercial |
$67.05
|
| Rate for Payer: Lutheran Preferred All Commercial |
$110.93
|
| Rate for Payer: Managed Health Services Medicaid |
$9.02
|
| Rate for Payer: MDWise Medicaid |
$9.02
|
| Rate for Payer: PHCS All Commercial |
$92.44
|
| Rate for Payer: PHP All Commercial |
$93.48
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$48.07
|
| Rate for Payer: Sagamore Health Network All Products |
$95.16
|
| Rate for Payer: Signature Care EPO |
$102.31
|
| Rate for Payer: Signature Care PPO |
$108.47
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$104.77
|
| Rate for Payer: United Healthcare Commercial |
$97.13
|
| Rate for Payer: United Healthcare Medicare |
$39.44
|
|
|
HC FREE T4
|
Facility
|
IP
|
$123.26
|
|
|
Service Code
|
CPT 84439
|
| Hospital Charge Code |
63001180
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$92.44 |
| Max. Negotiated Rate |
$114.63 |
| Rate for Payer: Aetna Commercial |
$106.50
|
| Rate for Payer: Cash Price |
$73.96
|
| Rate for Payer: Cigna All Commercial |
$106.37
|
| Rate for Payer: CORVEL All Commercial |
$114.63
|
| Rate for Payer: Coventry All Commercial |
$108.47
|
| Rate for Payer: Encore All Commercial |
$113.46
|
| Rate for Payer: Frontpath All Commercial |
$113.40
|
| Rate for Payer: Humana ChoiceCare |
$106.46
|
| Rate for Payer: Lutheran Preferred All Commercial |
$110.93
|
| Rate for Payer: PHCS All Commercial |
$92.44
|
| Rate for Payer: PHP All Commercial |
$93.48
|
| Rate for Payer: Sagamore Health Network All Products |
$95.16
|
| Rate for Payer: Signature Care EPO |
$102.31
|
| Rate for Payer: Signature Care PPO |
$108.47
|
| Rate for Payer: United Healthcare Commercial |
$97.13
|
|
|
HC FRESH FROZEN PLASMA
|
Facility
|
OP
|
$307.63
|
|
|
Service Code
|
CPT P9017
|
| Hospital Charge Code |
1370151
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$71.47 |
| Max. Negotiated Rate |
$286.10 |
| Rate for Payer: Aetna Commercial |
$259.64
|
| Rate for Payer: Aetna Medicare |
$98.44
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$71.47
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$95.37
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$176.67
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$192.30
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$71.47
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$113.21
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$108.29
|
| Rate for Payer: Cash Price |
$184.58
|
| Rate for Payer: Cash Price |
$184.58
|
| Rate for Payer: Centivo All Commercial |
$167.35
|
| Rate for Payer: Cigna All Commercial |
$265.48
|
| Rate for Payer: CORVEL All Commercial |
$286.10
|
| Rate for Payer: Coventry All Commercial |
$270.71
|
| Rate for Payer: Encore All Commercial |
$283.17
|
| Rate for Payer: Frontpath All Commercial |
$283.02
|
| Rate for Payer: Humana ChoiceCare |
$265.70
|
| Rate for Payer: Humana Medicare |
$98.44
|
| Rate for Payer: Lucent All Commercial |
$167.35
|
| Rate for Payer: Lutheran Preferred All Commercial |
$276.87
|
| Rate for Payer: Managed Health Services Medicaid |
$71.47
|
| Rate for Payer: MDWise Medicaid |
$71.47
|
| Rate for Payer: PHCS All Commercial |
$230.72
|
| Rate for Payer: PHP All Commercial |
$233.31
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$119.98
|
| Rate for Payer: Sagamore Health Network All Products |
$237.49
|
| Rate for Payer: Signature Care EPO |
$255.33
|
| Rate for Payer: Signature Care PPO |
$270.71
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$261.49
|
| Rate for Payer: United Healthcare Commercial |
$242.41
|
| Rate for Payer: United Healthcare Medicare |
$98.44
|
|
|
HC FRESH FROZEN PLASMA
|
Facility
|
IP
|
$307.63
|
|
|
Service Code
|
CPT P9017
|
| Hospital Charge Code |
1370151
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$230.72 |
| Max. Negotiated Rate |
$286.10 |
| Rate for Payer: Aetna Commercial |
$265.79
|
| Rate for Payer: Cash Price |
$184.58
|
| Rate for Payer: Cigna All Commercial |
$265.48
|
| Rate for Payer: CORVEL All Commercial |
$286.10
|
| Rate for Payer: Coventry All Commercial |
$270.71
|
| Rate for Payer: Encore All Commercial |
$283.17
|
| Rate for Payer: Frontpath All Commercial |
$283.02
|
| Rate for Payer: Humana ChoiceCare |
$265.70
|
| Rate for Payer: Lutheran Preferred All Commercial |
$276.87
|
| Rate for Payer: PHCS All Commercial |
$230.72
|
| Rate for Payer: PHP All Commercial |
$233.31
|
| Rate for Payer: Sagamore Health Network All Products |
$237.49
|
| Rate for Payer: Signature Care EPO |
$255.33
|
| Rate for Payer: Signature Care PPO |
$270.71
|
| Rate for Payer: United Healthcare Commercial |
$242.41
|
|
|
HC FROZEN SECTION PATH 1ST BLOCK
|
Facility
|
OP
|
$169.46
|
|
|
Service Code
|
CPT 88331 59
|
| Hospital Charge Code |
63002186
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$52.53 |
| Max. Negotiated Rate |
$157.60 |
| Rate for Payer: Aetna Commercial |
$143.02
|
| Rate for Payer: Aetna Medicare |
$54.23
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$63.83
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$52.53
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$77.88
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$77.88
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$63.83
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$62.36
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$59.65
|
| Rate for Payer: Cash Price |
$101.68
|
| Rate for Payer: Cash Price |
$101.68
|
| Rate for Payer: Centivo All Commercial |
$92.19
|
| Rate for Payer: Cigna All Commercial |
$146.24
|
| Rate for Payer: CORVEL All Commercial |
$157.60
|
| Rate for Payer: Coventry All Commercial |
$149.12
|
| Rate for Payer: Encore All Commercial |
$155.99
|
| Rate for Payer: Frontpath All Commercial |
$155.90
|
| Rate for Payer: Humana ChoiceCare |
$146.36
|
| Rate for Payer: Humana Medicare |
$54.23
|
| Rate for Payer: Lucent All Commercial |
$92.19
|
| Rate for Payer: Lutheran Preferred All Commercial |
$152.51
|
| Rate for Payer: Managed Health Services Medicaid |
$63.83
|
| Rate for Payer: MDWise Medicaid |
$63.83
|
| Rate for Payer: PHCS All Commercial |
$127.09
|
| Rate for Payer: PHP All Commercial |
$128.52
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$66.09
|
| Rate for Payer: Sagamore Health Network All Products |
$130.82
|
| Rate for Payer: Signature Care EPO |
$140.65
|
| Rate for Payer: Signature Care PPO |
$149.12
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$144.04
|
| Rate for Payer: United Healthcare Commercial |
$133.53
|
| Rate for Payer: United Healthcare Medicare |
$54.23
|
|
|
HC FROZEN SECTION PATH 1ST BLOCK
|
Facility
|
IP
|
$169.46
|
|
|
Service Code
|
CPT 88331 59
|
| Hospital Charge Code |
63002186
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$127.09 |
| Max. Negotiated Rate |
$157.60 |
| Rate for Payer: Aetna Commercial |
$146.41
|
| Rate for Payer: Cash Price |
$101.68
|
| Rate for Payer: Cigna All Commercial |
$146.24
|
| Rate for Payer: CORVEL All Commercial |
$157.60
|
| Rate for Payer: Coventry All Commercial |
$149.12
|
| Rate for Payer: Encore All Commercial |
$155.99
|
| Rate for Payer: Frontpath All Commercial |
$155.90
|
| Rate for Payer: Humana ChoiceCare |
$146.36
|
| Rate for Payer: Lutheran Preferred All Commercial |
$152.51
|
| Rate for Payer: PHCS All Commercial |
$127.09
|
| Rate for Payer: PHP All Commercial |
$128.52
|
| Rate for Payer: Sagamore Health Network All Products |
$130.82
|
| Rate for Payer: Signature Care EPO |
$140.65
|
| Rate for Payer: Signature Care PPO |
$149.12
|
| Rate for Payer: United Healthcare Commercial |
$133.53
|
|
|
HC FROZEN SECTION PATH EA ADDTL
|
Facility
|
OP
|
$121.82
|
|
|
Service Code
|
CPT 88332
|
| Hospital Charge Code |
63001262
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$31.91 |
| Max. Negotiated Rate |
$113.29 |
| Rate for Payer: Aetna Commercial |
$102.82
|
| Rate for Payer: Aetna Medicare |
$38.98
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$31.91
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$37.76
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$55.99
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$55.99
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$31.91
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$44.83
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$42.88
|
| Rate for Payer: Cash Price |
$73.09
|
| Rate for Payer: Cash Price |
$73.09
|
| Rate for Payer: Centivo All Commercial |
$66.27
|
| Rate for Payer: Cigna All Commercial |
$105.13
|
| Rate for Payer: CORVEL All Commercial |
$113.29
|
| Rate for Payer: Coventry All Commercial |
$107.20
|
| Rate for Payer: Encore All Commercial |
$112.14
|
| Rate for Payer: Frontpath All Commercial |
$112.07
|
| Rate for Payer: Humana ChoiceCare |
$105.22
|
| Rate for Payer: Humana Medicare |
$38.98
|
| Rate for Payer: Lucent All Commercial |
$66.27
|
| Rate for Payer: Lutheran Preferred All Commercial |
$109.64
|
| Rate for Payer: Managed Health Services Medicaid |
$31.91
|
| Rate for Payer: MDWise Medicaid |
$31.91
|
| Rate for Payer: PHCS All Commercial |
$91.36
|
| Rate for Payer: PHP All Commercial |
$92.39
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$47.51
|
| Rate for Payer: Sagamore Health Network All Products |
$94.05
|
| Rate for Payer: Signature Care EPO |
$101.11
|
| Rate for Payer: Signature Care PPO |
$107.20
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$103.55
|
| Rate for Payer: United Healthcare Commercial |
$95.99
|
| Rate for Payer: United Healthcare Medicare |
$38.98
|
|
|
HC FROZEN SECTION PATH EA ADDTL
|
Facility
|
IP
|
$121.82
|
|
|
Service Code
|
CPT 88332
|
| Hospital Charge Code |
63001262
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$91.36 |
| Max. Negotiated Rate |
$113.29 |
| Rate for Payer: Aetna Commercial |
$105.25
|
| Rate for Payer: Cash Price |
$73.09
|
| Rate for Payer: Cigna All Commercial |
$105.13
|
| Rate for Payer: CORVEL All Commercial |
$113.29
|
| Rate for Payer: Coventry All Commercial |
$107.20
|
| Rate for Payer: Encore All Commercial |
$112.14
|
| Rate for Payer: Frontpath All Commercial |
$112.07
|
| Rate for Payer: Humana ChoiceCare |
$105.22
|
| Rate for Payer: Lutheran Preferred All Commercial |
$109.64
|
| Rate for Payer: PHCS All Commercial |
$91.36
|
| Rate for Payer: PHP All Commercial |
$92.39
|
| Rate for Payer: Sagamore Health Network All Products |
$94.05
|
| Rate for Payer: Signature Care EPO |
$101.11
|
| Rate for Payer: Signature Care PPO |
$107.20
|
| Rate for Payer: United Healthcare Commercial |
$95.99
|
|
|
HC FSH
|
Facility
|
OP
|
$173.91
|
|
|
Service Code
|
CPT 83001
|
| Hospital Charge Code |
63001159
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.58 |
| Max. Negotiated Rate |
$161.74 |
| Rate for Payer: Aetna Commercial |
$146.78
|
| Rate for Payer: Aetna Medicare |
$55.65
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$18.58
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$53.91
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$79.93
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$79.93
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$18.58
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$64.00
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$61.22
|
| Rate for Payer: Cash Price |
$104.35
|
| Rate for Payer: Cash Price |
$104.35
|
| Rate for Payer: Centivo All Commercial |
$94.61
|
| Rate for Payer: Cigna All Commercial |
$150.08
|
| Rate for Payer: CORVEL All Commercial |
$161.74
|
| Rate for Payer: Coventry All Commercial |
$153.04
|
| Rate for Payer: Encore All Commercial |
$160.08
|
| Rate for Payer: Frontpath All Commercial |
$160.00
|
| Rate for Payer: Humana ChoiceCare |
$150.21
|
| Rate for Payer: Humana Medicare |
$55.65
|
| Rate for Payer: Lucent All Commercial |
$94.61
|
| Rate for Payer: Lutheran Preferred All Commercial |
$156.52
|
| Rate for Payer: Managed Health Services Medicaid |
$18.58
|
| Rate for Payer: MDWise Medicaid |
$18.58
|
| Rate for Payer: PHCS All Commercial |
$130.43
|
| Rate for Payer: PHP All Commercial |
$131.89
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$67.82
|
| Rate for Payer: Sagamore Health Network All Products |
$134.26
|
| Rate for Payer: Signature Care EPO |
$144.35
|
| Rate for Payer: Signature Care PPO |
$153.04
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$147.82
|
| Rate for Payer: United Healthcare Commercial |
$137.04
|
| Rate for Payer: United Healthcare Medicare |
$55.65
|
|
