|
HC HARMONIC SHEAR 36CM
|
Facility
|
IP
|
$2,877.38
|
|
| Hospital Charge Code |
41606644
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,158.03 |
| Max. Negotiated Rate |
$2,675.96 |
| Rate for Payer: Aetna Commercial |
$2,486.06
|
| Rate for Payer: Cash Price |
$1,726.43
|
| Rate for Payer: Cigna All Commercial |
$2,483.18
|
| Rate for Payer: CORVEL All Commercial |
$2,675.96
|
| Rate for Payer: Coventry All Commercial |
$2,532.09
|
| Rate for Payer: Encore All Commercial |
$2,648.63
|
| Rate for Payer: Frontpath All Commercial |
$2,647.19
|
| Rate for Payer: Humana ChoiceCare |
$2,485.19
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,589.64
|
| Rate for Payer: PHCS All Commercial |
$2,158.03
|
| Rate for Payer: PHP All Commercial |
$2,182.20
|
| Rate for Payer: Sagamore Health Network All Products |
$2,221.34
|
| Rate for Payer: Signature Care EPO |
$2,388.23
|
| Rate for Payer: Signature Care PPO |
$2,532.09
|
| Rate for Payer: United Healthcare Commercial |
$2,267.38
|
|
|
HC HBB (HEMOGLOBIN, SUBUNIT BETA)FULL GENE SQUENCE
|
Facility
|
OP
|
$3,220.14
|
|
|
Service Code
|
CPT 81364
|
| Hospital Charge Code |
63081364
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$324.58 |
| Max. Negotiated Rate |
$2,994.73 |
| Rate for Payer: Aetna Commercial |
$2,717.80
|
| Rate for Payer: Aetna Medicare |
$1,030.44
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$324.58
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$998.24
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1,479.98
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,479.98
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$324.58
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1,185.01
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1,133.49
|
| Rate for Payer: Cash Price |
$1,932.08
|
| Rate for Payer: Cash Price |
$1,932.08
|
| Rate for Payer: Centivo All Commercial |
$1,751.76
|
| Rate for Payer: Cigna All Commercial |
$2,778.98
|
| Rate for Payer: CORVEL All Commercial |
$2,994.73
|
| Rate for Payer: Coventry All Commercial |
$2,833.72
|
| Rate for Payer: Encore All Commercial |
$2,964.14
|
| Rate for Payer: Frontpath All Commercial |
$2,962.53
|
| Rate for Payer: Humana ChoiceCare |
$2,781.23
|
| Rate for Payer: Humana Medicare |
$1,030.44
|
| Rate for Payer: Lucent All Commercial |
$1,751.76
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,898.13
|
| Rate for Payer: Managed Health Services Medicaid |
$324.58
|
| Rate for Payer: MDWise Medicaid |
$324.58
|
| Rate for Payer: PHCS All Commercial |
$2,415.11
|
| Rate for Payer: PHP All Commercial |
$2,442.15
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1,255.85
|
| Rate for Payer: Sagamore Health Network All Products |
$2,485.95
|
| Rate for Payer: Signature Care EPO |
$2,672.72
|
| Rate for Payer: Signature Care PPO |
$2,833.72
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2,737.12
|
| Rate for Payer: United Healthcare Commercial |
$2,537.47
|
| Rate for Payer: United Healthcare Medicare |
$1,030.44
|
|
|
HC HBB (HEMOGLOBIN, SUBUNIT BETA)FULL GENE SQUENCE
|
Facility
|
IP
|
$3,220.14
|
|
|
Service Code
|
CPT 81364
|
| Hospital Charge Code |
63081364
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$2,415.11 |
| Max. Negotiated Rate |
$2,994.73 |
| Rate for Payer: Aetna Commercial |
$2,782.20
|
| Rate for Payer: Cash Price |
$1,932.08
|
| Rate for Payer: Cigna All Commercial |
$2,778.98
|
| Rate for Payer: CORVEL All Commercial |
$2,994.73
|
| Rate for Payer: Coventry All Commercial |
$2,833.72
|
| Rate for Payer: Encore All Commercial |
$2,964.14
|
| Rate for Payer: Frontpath All Commercial |
$2,962.53
|
| Rate for Payer: Humana ChoiceCare |
$2,781.23
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,898.13
|
| Rate for Payer: PHCS All Commercial |
$2,415.11
|
| Rate for Payer: PHP All Commercial |
$2,442.15
|
| Rate for Payer: Sagamore Health Network All Products |
$2,485.95
|
| Rate for Payer: Signature Care EPO |
$2,672.72
|
| Rate for Payer: Signature Care PPO |
$2,833.72
|
| Rate for Payer: United Healthcare Commercial |
$2,537.47
|
|
|
HC HCG PREG TEST QUAL
|
Facility
|
IP
|
$109.40
|
|
|
Service Code
|
CPT 84703
|
| Hospital Charge Code |
63001331
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$82.05 |
| Max. Negotiated Rate |
$101.74 |
| Rate for Payer: Aetna Commercial |
$94.52
|
| Rate for Payer: Cash Price |
$65.64
|
| Rate for Payer: Cigna All Commercial |
$94.41
|
| Rate for Payer: CORVEL All Commercial |
$101.74
|
| Rate for Payer: Coventry All Commercial |
$96.27
|
| Rate for Payer: Encore All Commercial |
$100.70
|
| Rate for Payer: Frontpath All Commercial |
$100.65
|
| Rate for Payer: Humana ChoiceCare |
$94.49
|
| Rate for Payer: Lutheran Preferred All Commercial |
$98.46
|
| Rate for Payer: PHCS All Commercial |
$82.05
|
| Rate for Payer: PHP All Commercial |
$82.97
|
| Rate for Payer: Sagamore Health Network All Products |
$84.46
|
| Rate for Payer: Signature Care EPO |
$90.80
|
| Rate for Payer: Signature Care PPO |
$96.27
|
| Rate for Payer: United Healthcare Commercial |
$86.21
|
|
|
HC HCG PREG TEST QUAL
|
Facility
|
OP
|
$109.40
|
|
|
Service Code
|
CPT 84703
|
| Hospital Charge Code |
63001331
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$7.52 |
| Max. Negotiated Rate |
$101.74 |
| Rate for Payer: Aetna Commercial |
$92.33
|
| Rate for Payer: Aetna Medicare |
$35.01
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$7.52
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$33.91
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$50.28
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$50.28
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$7.52
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$40.26
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$38.51
|
| Rate for Payer: Cash Price |
$65.64
|
| Rate for Payer: Cash Price |
$65.64
|
| Rate for Payer: Centivo All Commercial |
$59.51
|
| Rate for Payer: Cigna All Commercial |
$94.41
|
| Rate for Payer: CORVEL All Commercial |
$101.74
|
| Rate for Payer: Coventry All Commercial |
$96.27
|
| Rate for Payer: Encore All Commercial |
$100.70
|
| Rate for Payer: Frontpath All Commercial |
$100.65
|
| Rate for Payer: Humana ChoiceCare |
$94.49
|
| Rate for Payer: Humana Medicare |
$35.01
|
| Rate for Payer: Lucent All Commercial |
$59.51
|
| Rate for Payer: Lutheran Preferred All Commercial |
$98.46
|
| Rate for Payer: Managed Health Services Medicaid |
$7.52
|
| Rate for Payer: MDWise Medicaid |
$7.52
|
| Rate for Payer: PHCS All Commercial |
$82.05
|
| Rate for Payer: PHP All Commercial |
$82.97
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$42.67
|
| Rate for Payer: Sagamore Health Network All Products |
$84.46
|
| Rate for Payer: Signature Care EPO |
$90.80
|
| Rate for Payer: Signature Care PPO |
$96.27
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$92.99
|
| Rate for Payer: United Healthcare Commercial |
$86.21
|
| Rate for Payer: United Healthcare Medicare |
$35.01
|
|
|
HC HCT
|
Facility
|
IP
|
$57.22
|
|
|
Service Code
|
CPT 85014
|
| Hospital Charge Code |
63001237
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$42.91 |
| Max. Negotiated Rate |
$53.21 |
| Rate for Payer: Aetna Commercial |
$49.44
|
| Rate for Payer: Cash Price |
$34.33
|
| Rate for Payer: Cigna All Commercial |
$49.38
|
| Rate for Payer: CORVEL All Commercial |
$53.21
|
| Rate for Payer: Coventry All Commercial |
$50.35
|
| Rate for Payer: Encore All Commercial |
$52.67
|
| Rate for Payer: Frontpath All Commercial |
$52.64
|
| Rate for Payer: Humana ChoiceCare |
$49.42
|
| Rate for Payer: Lutheran Preferred All Commercial |
$51.50
|
| Rate for Payer: PHCS All Commercial |
$42.91
|
| Rate for Payer: PHP All Commercial |
$43.40
|
| Rate for Payer: Sagamore Health Network All Products |
$44.17
|
| Rate for Payer: Signature Care EPO |
$47.49
|
| Rate for Payer: Signature Care PPO |
$50.35
|
| Rate for Payer: United Healthcare Commercial |
$45.09
|
|
|
HC HCT
|
Facility
|
OP
|
$57.22
|
|
|
Service Code
|
CPT 85014
|
| Hospital Charge Code |
63001237
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$2.37 |
| Max. Negotiated Rate |
$53.21 |
| Rate for Payer: Aetna Commercial |
$48.29
|
| Rate for Payer: Aetna Medicare |
$18.31
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$2.37
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$17.74
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$26.30
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$26.30
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$2.37
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$21.06
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$20.14
|
| Rate for Payer: Cash Price |
$34.33
|
| Rate for Payer: Cash Price |
$34.33
|
| Rate for Payer: Centivo All Commercial |
$31.13
|
| Rate for Payer: Cigna All Commercial |
$49.38
|
| Rate for Payer: CORVEL All Commercial |
$53.21
|
| Rate for Payer: Coventry All Commercial |
$50.35
|
| Rate for Payer: Encore All Commercial |
$52.67
|
| Rate for Payer: Frontpath All Commercial |
$52.64
|
| Rate for Payer: Humana ChoiceCare |
$49.42
|
| Rate for Payer: Humana Medicare |
$18.31
|
| Rate for Payer: Lucent All Commercial |
$31.13
|
| Rate for Payer: Lutheran Preferred All Commercial |
$51.50
|
| Rate for Payer: Managed Health Services Medicaid |
$2.37
|
| Rate for Payer: MDWise Medicaid |
$2.37
|
| Rate for Payer: PHCS All Commercial |
$42.91
|
| Rate for Payer: PHP All Commercial |
$43.40
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$22.32
|
| Rate for Payer: Sagamore Health Network All Products |
$44.17
|
| Rate for Payer: Signature Care EPO |
$47.49
|
| Rate for Payer: Signature Care PPO |
$50.35
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$48.64
|
| Rate for Payer: United Healthcare Commercial |
$45.09
|
| Rate for Payer: United Healthcare Medicare |
$18.31
|
|
|
HC HDL
|
Facility
|
OP
|
$73.27
|
|
|
Service Code
|
CPT 83718
|
| Hospital Charge Code |
63001319
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.19 |
| Max. Negotiated Rate |
$68.14 |
| Rate for Payer: Aetna Commercial |
$61.84
|
| Rate for Payer: Aetna Medicare |
$23.45
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$8.19
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$22.71
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$33.67
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$33.67
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$8.19
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$26.96
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$25.79
|
| Rate for Payer: Cash Price |
$43.96
|
| Rate for Payer: Cash Price |
$43.96
|
| Rate for Payer: Centivo All Commercial |
$39.86
|
| Rate for Payer: Cigna All Commercial |
$63.23
|
| Rate for Payer: CORVEL All Commercial |
$68.14
|
| Rate for Payer: Coventry All Commercial |
$64.48
|
| Rate for Payer: Encore All Commercial |
$67.45
|
| Rate for Payer: Frontpath All Commercial |
$67.41
|
| Rate for Payer: Humana ChoiceCare |
$63.28
|
| Rate for Payer: Humana Medicare |
$23.45
|
| Rate for Payer: Lucent All Commercial |
$39.86
|
| Rate for Payer: Lutheran Preferred All Commercial |
$65.94
|
| Rate for Payer: Managed Health Services Medicaid |
$8.19
|
| Rate for Payer: MDWise Medicaid |
$8.19
|
| Rate for Payer: PHCS All Commercial |
$54.95
|
| Rate for Payer: PHP All Commercial |
$55.57
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$28.58
|
| Rate for Payer: Sagamore Health Network All Products |
$56.56
|
| Rate for Payer: Signature Care EPO |
$60.81
|
| Rate for Payer: Signature Care PPO |
$64.48
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$62.28
|
| Rate for Payer: United Healthcare Commercial |
$57.74
|
| Rate for Payer: United Healthcare Medicare |
$23.45
|
|
|
HC HDL
|
Facility
|
IP
|
$73.27
|
|
|
Service Code
|
CPT 83718
|
| Hospital Charge Code |
63001319
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$54.95 |
| Max. Negotiated Rate |
$68.14 |
| Rate for Payer: Aetna Commercial |
$63.31
|
| Rate for Payer: Cash Price |
$43.96
|
| Rate for Payer: Cigna All Commercial |
$63.23
|
| Rate for Payer: CORVEL All Commercial |
$68.14
|
| Rate for Payer: Coventry All Commercial |
$64.48
|
| Rate for Payer: Encore All Commercial |
$67.45
|
| Rate for Payer: Frontpath All Commercial |
$67.41
|
| Rate for Payer: Humana ChoiceCare |
$63.28
|
| Rate for Payer: Lutheran Preferred All Commercial |
$65.94
|
| Rate for Payer: PHCS All Commercial |
$54.95
|
| Rate for Payer: PHP All Commercial |
$55.57
|
| Rate for Payer: Sagamore Health Network All Products |
$56.56
|
| Rate for Payer: Signature Care EPO |
$60.81
|
| Rate for Payer: Signature Care PPO |
$64.48
|
| Rate for Payer: United Healthcare Commercial |
$57.74
|
|
|
HC HE4, OVARIAN CANCER MONITORING
|
Facility
|
IP
|
$1,005.38
|
|
|
Service Code
|
CPT 86305
|
| Hospital Charge Code |
63001036
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$754.03 |
| Max. Negotiated Rate |
$935.00 |
| Rate for Payer: Aetna Commercial |
$868.65
|
| Rate for Payer: Cash Price |
$603.23
|
| Rate for Payer: Cigna All Commercial |
$867.64
|
| Rate for Payer: CORVEL All Commercial |
$935.00
|
| Rate for Payer: Coventry All Commercial |
$884.73
|
| Rate for Payer: Encore All Commercial |
$925.45
|
| Rate for Payer: Frontpath All Commercial |
$924.95
|
| Rate for Payer: Humana ChoiceCare |
$868.35
|
| Rate for Payer: Lutheran Preferred All Commercial |
$904.84
|
| Rate for Payer: PHCS All Commercial |
$754.03
|
| Rate for Payer: PHP All Commercial |
$762.48
|
| Rate for Payer: Sagamore Health Network All Products |
$776.15
|
| Rate for Payer: Signature Care EPO |
$834.47
|
| Rate for Payer: Signature Care PPO |
$884.73
|
| Rate for Payer: United Healthcare Commercial |
$792.24
|
|
|
HC HE4, OVARIAN CANCER MONITORING
|
Facility
|
OP
|
$1,005.38
|
|
|
Service Code
|
CPT 86305
|
| Hospital Charge Code |
63001036
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$20.81 |
| Max. Negotiated Rate |
$935.00 |
| Rate for Payer: Aetna Commercial |
$848.54
|
| Rate for Payer: Aetna Medicare |
$321.72
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$20.81
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$311.67
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$462.07
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$462.07
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$20.81
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$369.98
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$353.89
|
| Rate for Payer: Cash Price |
$603.23
|
| Rate for Payer: Cash Price |
$603.23
|
| Rate for Payer: Centivo All Commercial |
$546.93
|
| Rate for Payer: Cigna All Commercial |
$867.64
|
| Rate for Payer: CORVEL All Commercial |
$935.00
|
| Rate for Payer: Coventry All Commercial |
$884.73
|
| Rate for Payer: Encore All Commercial |
$925.45
|
| Rate for Payer: Frontpath All Commercial |
$924.95
|
| Rate for Payer: Humana ChoiceCare |
$868.35
|
| Rate for Payer: Humana Medicare |
$321.72
|
| Rate for Payer: Lucent All Commercial |
$546.93
|
| Rate for Payer: Lutheran Preferred All Commercial |
$904.84
|
| Rate for Payer: Managed Health Services Medicaid |
$20.81
|
| Rate for Payer: MDWise Medicaid |
$20.81
|
| Rate for Payer: PHCS All Commercial |
$754.03
|
| Rate for Payer: PHP All Commercial |
$762.48
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$392.10
|
| Rate for Payer: Sagamore Health Network All Products |
$776.15
|
| Rate for Payer: Signature Care EPO |
$834.47
|
| Rate for Payer: Signature Care PPO |
$884.73
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$854.57
|
| Rate for Payer: United Healthcare Commercial |
$792.24
|
| Rate for Payer: United Healthcare Medicare |
$321.72
|
|
|
HC HEART SCAN SPECT MULTIPLE
|
Facility
|
OP
|
$6,352.10
|
|
|
Service Code
|
CPT 78452
|
| Hospital Charge Code |
1639452
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$280.83 |
| Max. Negotiated Rate |
$5,907.45 |
| Rate for Payer: Aetna Commercial |
$5,361.17
|
| Rate for Payer: Aetna Medicare |
$2,032.67
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$280.83
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1,969.15
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$3,648.01
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3,970.70
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$280.83
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2,337.57
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2,235.94
|
| Rate for Payer: Cash Price |
$3,811.26
|
| Rate for Payer: Cash Price |
$3,811.26
|
| Rate for Payer: Centivo All Commercial |
$3,455.54
|
| Rate for Payer: Cigna All Commercial |
$5,481.86
|
| Rate for Payer: CORVEL All Commercial |
$5,907.45
|
| Rate for Payer: Coventry All Commercial |
$5,589.85
|
| Rate for Payer: Encore All Commercial |
$5,847.11
|
| Rate for Payer: Frontpath All Commercial |
$5,843.93
|
| Rate for Payer: Humana ChoiceCare |
$5,486.31
|
| Rate for Payer: Humana Medicare |
$2,032.67
|
| Rate for Payer: Lucent All Commercial |
$3,455.54
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5,716.89
|
| Rate for Payer: Managed Health Services Medicaid |
$280.83
|
| Rate for Payer: MDWise Medicaid |
$280.83
|
| Rate for Payer: PHCS All Commercial |
$4,764.07
|
| Rate for Payer: PHP All Commercial |
$4,817.43
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2,477.32
|
| Rate for Payer: Sagamore Health Network All Products |
$4,903.82
|
| Rate for Payer: Signature Care EPO |
$5,272.24
|
| Rate for Payer: Signature Care PPO |
$5,589.85
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$5,399.28
|
| Rate for Payer: United Healthcare Commercial |
$5,005.45
|
| Rate for Payer: United Healthcare Medicare |
$2,032.67
|
|
|
HC HEART SCAN SPECT MULTIPLE
|
Facility
|
IP
|
$6,352.10
|
|
|
Service Code
|
CPT 78452
|
| Hospital Charge Code |
1639452
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$4,764.07 |
| Max. Negotiated Rate |
$5,907.45 |
| Rate for Payer: Aetna Commercial |
$5,488.21
|
| Rate for Payer: Cash Price |
$3,811.26
|
| Rate for Payer: Cigna All Commercial |
$5,481.86
|
| Rate for Payer: CORVEL All Commercial |
$5,907.45
|
| Rate for Payer: Coventry All Commercial |
$5,589.85
|
| Rate for Payer: Encore All Commercial |
$5,847.11
|
| Rate for Payer: Frontpath All Commercial |
$5,843.93
|
| Rate for Payer: Humana ChoiceCare |
$5,486.31
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5,716.89
|
| Rate for Payer: PHCS All Commercial |
$4,764.07
|
| Rate for Payer: PHP All Commercial |
$4,817.43
|
| Rate for Payer: Sagamore Health Network All Products |
$4,903.82
|
| Rate for Payer: Signature Care EPO |
$5,272.24
|
| Rate for Payer: Signature Care PPO |
$5,589.85
|
| Rate for Payer: United Healthcare Commercial |
$5,005.45
|
|
|
HC HEART SCAN SPECT SINGLE
|
Facility
|
OP
|
$3,207.02
|
|
|
Service Code
|
CPT 78451
|
| Hospital Charge Code |
1639451
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$195.20 |
| Max. Negotiated Rate |
$2,982.53 |
| Rate for Payer: Aetna Commercial |
$2,706.72
|
| Rate for Payer: Aetna Medicare |
$1,026.25
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$195.20
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$994.18
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1,841.79
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2,004.71
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$195.20
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1,180.18
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1,128.87
|
| Rate for Payer: Cash Price |
$1,924.21
|
| Rate for Payer: Cash Price |
$1,924.21
|
| Rate for Payer: Centivo All Commercial |
$1,744.62
|
| Rate for Payer: Cigna All Commercial |
$2,767.66
|
| Rate for Payer: CORVEL All Commercial |
$2,982.53
|
| Rate for Payer: Coventry All Commercial |
$2,822.18
|
| Rate for Payer: Encore All Commercial |
$2,952.06
|
| Rate for Payer: Frontpath All Commercial |
$2,950.46
|
| Rate for Payer: Humana ChoiceCare |
$2,769.90
|
| Rate for Payer: Humana Medicare |
$1,026.25
|
| Rate for Payer: Lucent All Commercial |
$1,744.62
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,886.32
|
| Rate for Payer: Managed Health Services Medicaid |
$195.20
|
| Rate for Payer: MDWise Medicaid |
$195.20
|
| Rate for Payer: PHCS All Commercial |
$2,405.26
|
| Rate for Payer: PHP All Commercial |
$2,432.20
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1,250.74
|
| Rate for Payer: Sagamore Health Network All Products |
$2,475.82
|
| Rate for Payer: Signature Care EPO |
$2,661.83
|
| Rate for Payer: Signature Care PPO |
$2,822.18
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2,725.97
|
| Rate for Payer: United Healthcare Commercial |
$2,527.13
|
| Rate for Payer: United Healthcare Medicare |
$1,026.25
|
|
|
HC HEART SCAN SPECT SINGLE
|
Facility
|
IP
|
$3,207.02
|
|
|
Service Code
|
CPT 78451
|
| Hospital Charge Code |
1639451
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$2,405.26 |
| Max. Negotiated Rate |
$2,982.53 |
| Rate for Payer: Aetna Commercial |
$2,770.87
|
| Rate for Payer: Cash Price |
$1,924.21
|
| Rate for Payer: Cigna All Commercial |
$2,767.66
|
| Rate for Payer: CORVEL All Commercial |
$2,982.53
|
| Rate for Payer: Coventry All Commercial |
$2,822.18
|
| Rate for Payer: Encore All Commercial |
$2,952.06
|
| Rate for Payer: Frontpath All Commercial |
$2,950.46
|
| Rate for Payer: Humana ChoiceCare |
$2,769.90
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,886.32
|
| Rate for Payer: PHCS All Commercial |
$2,405.26
|
| Rate for Payer: PHP All Commercial |
$2,432.20
|
| Rate for Payer: Sagamore Health Network All Products |
$2,475.82
|
| Rate for Payer: Signature Care EPO |
$2,661.83
|
| Rate for Payer: Signature Care PPO |
$2,822.18
|
| Rate for Payer: United Healthcare Commercial |
$2,527.13
|
|
|
HC HEART SMART CT
|
Facility
|
OP
|
$50.00
|
|
|
Service Code
|
CPT 75571 GY
|
| Hospital Charge Code |
1669971
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$15.50 |
| Max. Negotiated Rate |
$53.92 |
| Rate for Payer: Aetna Commercial |
$42.20
|
| Rate for Payer: Aetna Medicare |
$16.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$53.92
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$15.50
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$28.71
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$31.25
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$53.92
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$18.40
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$17.60
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Centivo All Commercial |
$27.20
|
| Rate for Payer: Cigna All Commercial |
$43.15
|
| Rate for Payer: CORVEL All Commercial |
$46.50
|
| Rate for Payer: Coventry All Commercial |
$44.00
|
| Rate for Payer: Encore All Commercial |
$46.02
|
| Rate for Payer: Frontpath All Commercial |
$46.00
|
| Rate for Payer: Humana ChoiceCare |
$43.19
|
| Rate for Payer: Humana Medicare |
$16.00
|
| Rate for Payer: Lucent All Commercial |
$27.20
|
| Rate for Payer: Lutheran Preferred All Commercial |
$45.00
|
| Rate for Payer: Managed Health Services Medicaid |
$53.92
|
| Rate for Payer: MDWise Medicaid |
$53.92
|
| Rate for Payer: PHCS All Commercial |
$37.50
|
| Rate for Payer: PHP All Commercial |
$37.92
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$19.50
|
| Rate for Payer: Sagamore Health Network All Products |
$38.60
|
| Rate for Payer: Signature Care EPO |
$41.50
|
| Rate for Payer: Signature Care PPO |
$44.00
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$42.50
|
| Rate for Payer: United Healthcare Commercial |
$39.40
|
| Rate for Payer: United Healthcare Medicare |
$16.00
|
|
|
HC HEART SMART CT
|
Facility
|
IP
|
$50.00
|
|
|
Service Code
|
CPT 75571 GY
|
| Hospital Charge Code |
1669971
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$37.50 |
| Max. Negotiated Rate |
$46.50 |
| Rate for Payer: Aetna Commercial |
$43.20
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna All Commercial |
$43.15
|
| Rate for Payer: CORVEL All Commercial |
$46.50
|
| Rate for Payer: Coventry All Commercial |
$44.00
|
| Rate for Payer: Encore All Commercial |
$46.02
|
| Rate for Payer: Frontpath All Commercial |
$46.00
|
| Rate for Payer: Humana ChoiceCare |
$43.19
|
| Rate for Payer: Lutheran Preferred All Commercial |
$45.00
|
| Rate for Payer: PHCS All Commercial |
$37.50
|
| Rate for Payer: PHP All Commercial |
$37.92
|
| Rate for Payer: Sagamore Health Network All Products |
$38.60
|
| Rate for Payer: Signature Care EPO |
$41.50
|
| Rate for Payer: Signature Care PPO |
$44.00
|
| Rate for Payer: United Healthcare Commercial |
$39.40
|
|
|
HC HEEL LIFT STANDARD SMOOTH
|
Facility
|
IP
|
$281.96
|
|
|
Service Code
|
CPT E0191
|
| Hospital Charge Code |
41601454
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$211.47 |
| Max. Negotiated Rate |
$262.22 |
| Rate for Payer: Aetna Commercial |
$243.61
|
| Rate for Payer: Cash Price |
$169.18
|
| Rate for Payer: Cigna All Commercial |
$243.33
|
| Rate for Payer: CORVEL All Commercial |
$262.22
|
| Rate for Payer: Coventry All Commercial |
$248.12
|
| Rate for Payer: Encore All Commercial |
$259.54
|
| Rate for Payer: Frontpath All Commercial |
$259.40
|
| Rate for Payer: Humana ChoiceCare |
$243.53
|
| Rate for Payer: Lutheran Preferred All Commercial |
$253.76
|
| Rate for Payer: PHCS All Commercial |
$211.47
|
| Rate for Payer: PHP All Commercial |
$213.84
|
| Rate for Payer: Sagamore Health Network All Products |
$217.67
|
| Rate for Payer: Signature Care EPO |
$234.03
|
| Rate for Payer: Signature Care PPO |
$248.12
|
| Rate for Payer: United Healthcare Commercial |
$222.18
|
|
|
HC HEEL LIFT STANDARD SMOOTH
|
Facility
|
OP
|
$281.96
|
|
|
Service Code
|
CPT E0191
|
| Hospital Charge Code |
41601454
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$21.01 |
| Max. Negotiated Rate |
$262.22 |
| Rate for Payer: Aetna Commercial |
$237.97
|
| Rate for Payer: Aetna Medicare |
$90.23
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$21.01
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$87.41
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$161.93
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$176.25
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$21.01
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$103.76
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$99.25
|
| Rate for Payer: Cash Price |
$169.18
|
| Rate for Payer: Cash Price |
$169.18
|
| Rate for Payer: Centivo All Commercial |
$153.39
|
| Rate for Payer: Cigna All Commercial |
$243.33
|
| Rate for Payer: CORVEL All Commercial |
$262.22
|
| Rate for Payer: Coventry All Commercial |
$248.12
|
| Rate for Payer: Encore All Commercial |
$259.54
|
| Rate for Payer: Frontpath All Commercial |
$259.40
|
| Rate for Payer: Humana ChoiceCare |
$243.53
|
| Rate for Payer: Humana Medicare |
$90.23
|
| Rate for Payer: Lucent All Commercial |
$153.39
|
| Rate for Payer: Lutheran Preferred All Commercial |
$253.76
|
| Rate for Payer: Managed Health Services Medicaid |
$21.01
|
| Rate for Payer: MDWise Medicaid |
$21.01
|
| Rate for Payer: PHCS All Commercial |
$211.47
|
| Rate for Payer: PHP All Commercial |
$213.84
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$109.96
|
| Rate for Payer: Sagamore Health Network All Products |
$217.67
|
| Rate for Payer: Signature Care EPO |
$234.03
|
| Rate for Payer: Signature Care PPO |
$248.12
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$239.67
|
| Rate for Payer: United Healthcare Commercial |
$222.18
|
| Rate for Payer: United Healthcare Medicare |
$90.23
|
|
|
HC HELICOBACTER PYLORIA AG-FECES
|
Facility
|
IP
|
$235.62
|
|
|
Service Code
|
CPT 87338
|
| Hospital Charge Code |
63002029
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$176.72 |
| Max. Negotiated Rate |
$219.13 |
| Rate for Payer: Aetna Commercial |
$203.58
|
| Rate for Payer: Cash Price |
$141.37
|
| Rate for Payer: Cigna All Commercial |
$203.34
|
| Rate for Payer: CORVEL All Commercial |
$219.13
|
| Rate for Payer: Coventry All Commercial |
$207.35
|
| Rate for Payer: Encore All Commercial |
$216.89
|
| Rate for Payer: Frontpath All Commercial |
$216.77
|
| Rate for Payer: Humana ChoiceCare |
$203.50
|
| Rate for Payer: Lutheran Preferred All Commercial |
$212.06
|
| Rate for Payer: PHCS All Commercial |
$176.72
|
| Rate for Payer: PHP All Commercial |
$178.69
|
| Rate for Payer: Sagamore Health Network All Products |
$181.90
|
| Rate for Payer: Signature Care EPO |
$195.56
|
| Rate for Payer: Signature Care PPO |
$207.35
|
| Rate for Payer: United Healthcare Commercial |
$185.67
|
|
|
HC HELICOBACTER PYLORIA AG-FECES
|
Facility
|
OP
|
$235.62
|
|
|
Service Code
|
CPT 87338
|
| Hospital Charge Code |
63002029
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.38 |
| Max. Negotiated Rate |
$219.13 |
| Rate for Payer: Aetna Commercial |
$198.86
|
| Rate for Payer: Aetna Medicare |
$75.40
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$14.38
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$73.04
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$108.29
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$108.29
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$14.38
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$86.71
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$82.94
|
| Rate for Payer: Cash Price |
$141.37
|
| Rate for Payer: Cash Price |
$141.37
|
| Rate for Payer: Centivo All Commercial |
$128.18
|
| Rate for Payer: Cigna All Commercial |
$203.34
|
| Rate for Payer: CORVEL All Commercial |
$219.13
|
| Rate for Payer: Coventry All Commercial |
$207.35
|
| Rate for Payer: Encore All Commercial |
$216.89
|
| Rate for Payer: Frontpath All Commercial |
$216.77
|
| Rate for Payer: Humana ChoiceCare |
$203.50
|
| Rate for Payer: Humana Medicare |
$75.40
|
| Rate for Payer: Lucent All Commercial |
$128.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$212.06
|
| Rate for Payer: Managed Health Services Medicaid |
$14.38
|
| Rate for Payer: MDWise Medicaid |
$14.38
|
| Rate for Payer: PHCS All Commercial |
$176.72
|
| Rate for Payer: PHP All Commercial |
$178.69
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$91.89
|
| Rate for Payer: Sagamore Health Network All Products |
$181.90
|
| Rate for Payer: Signature Care EPO |
$195.56
|
| Rate for Payer: Signature Care PPO |
$207.35
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$200.28
|
| Rate for Payer: United Healthcare Commercial |
$185.67
|
| Rate for Payer: United Healthcare Medicare |
$75.40
|
|
|
HC HELICOBACTER PYLORI UREASE BREATH TEST
|
Facility
|
IP
|
$396.07
|
|
|
Service Code
|
CPT 83013
|
| Hospital Charge Code |
63001053
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$297.05 |
| Max. Negotiated Rate |
$368.35 |
| Rate for Payer: Aetna Commercial |
$342.20
|
| Rate for Payer: Cash Price |
$237.64
|
| Rate for Payer: Cigna All Commercial |
$341.81
|
| Rate for Payer: CORVEL All Commercial |
$368.35
|
| Rate for Payer: Coventry All Commercial |
$348.54
|
| Rate for Payer: Encore All Commercial |
$364.58
|
| Rate for Payer: Frontpath All Commercial |
$364.38
|
| Rate for Payer: Humana ChoiceCare |
$342.09
|
| Rate for Payer: Lutheran Preferred All Commercial |
$356.46
|
| Rate for Payer: PHCS All Commercial |
$297.05
|
| Rate for Payer: PHP All Commercial |
$300.38
|
| Rate for Payer: Sagamore Health Network All Products |
$305.77
|
| Rate for Payer: Signature Care EPO |
$328.74
|
| Rate for Payer: Signature Care PPO |
$348.54
|
| Rate for Payer: United Healthcare Commercial |
$312.10
|
|
|
HC HELICOBACTER PYLORI UREASE BREATH TEST
|
Facility
|
OP
|
$396.07
|
|
|
Service Code
|
CPT 83013
|
| Hospital Charge Code |
63001053
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$67.36 |
| Max. Negotiated Rate |
$368.35 |
| Rate for Payer: Aetna Commercial |
$334.28
|
| Rate for Payer: Aetna Medicare |
$126.74
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$67.36
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$122.78
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$182.03
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$182.03
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$67.36
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$145.75
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$139.42
|
| Rate for Payer: Cash Price |
$237.64
|
| Rate for Payer: Cash Price |
$237.64
|
| Rate for Payer: Centivo All Commercial |
$215.46
|
| Rate for Payer: Cigna All Commercial |
$341.81
|
| Rate for Payer: CORVEL All Commercial |
$368.35
|
| Rate for Payer: Coventry All Commercial |
$348.54
|
| Rate for Payer: Encore All Commercial |
$364.58
|
| Rate for Payer: Frontpath All Commercial |
$364.38
|
| Rate for Payer: Humana ChoiceCare |
$342.09
|
| Rate for Payer: Humana Medicare |
$126.74
|
| Rate for Payer: Lucent All Commercial |
$215.46
|
| Rate for Payer: Lutheran Preferred All Commercial |
$356.46
|
| Rate for Payer: Managed Health Services Medicaid |
$67.36
|
| Rate for Payer: MDWise Medicaid |
$67.36
|
| Rate for Payer: PHCS All Commercial |
$297.05
|
| Rate for Payer: PHP All Commercial |
$300.38
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$154.47
|
| Rate for Payer: Sagamore Health Network All Products |
$305.77
|
| Rate for Payer: Signature Care EPO |
$328.74
|
| Rate for Payer: Signature Care PPO |
$348.54
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$336.66
|
| Rate for Payer: United Healthcare Commercial |
$312.10
|
| Rate for Payer: United Healthcare Medicare |
$126.74
|
|
|
HC HEMACHROM MUTATION HEREDITARY
|
Facility
|
OP
|
$988.48
|
|
|
Service Code
|
CPT 81256
|
| Hospital Charge Code |
63001438
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$65.36 |
| Max. Negotiated Rate |
$919.29 |
| Rate for Payer: Aetna Commercial |
$834.28
|
| Rate for Payer: Aetna Medicare |
$316.31
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$65.36
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$306.43
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$454.31
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$454.31
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$65.36
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$363.76
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$347.94
|
| Rate for Payer: Cash Price |
$593.09
|
| Rate for Payer: Cash Price |
$593.09
|
| Rate for Payer: Centivo All Commercial |
$537.73
|
| Rate for Payer: Cigna All Commercial |
$853.06
|
| Rate for Payer: CORVEL All Commercial |
$919.29
|
| Rate for Payer: Coventry All Commercial |
$869.86
|
| Rate for Payer: Encore All Commercial |
$909.90
|
| Rate for Payer: Frontpath All Commercial |
$909.40
|
| Rate for Payer: Humana ChoiceCare |
$853.75
|
| Rate for Payer: Humana Medicare |
$316.31
|
| Rate for Payer: Lucent All Commercial |
$537.73
|
| Rate for Payer: Lutheran Preferred All Commercial |
$889.63
|
| Rate for Payer: Managed Health Services Medicaid |
$65.36
|
| Rate for Payer: MDWise Medicaid |
$65.36
|
| Rate for Payer: PHCS All Commercial |
$741.36
|
| Rate for Payer: PHP All Commercial |
$749.66
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$385.51
|
| Rate for Payer: Sagamore Health Network All Products |
$763.11
|
| Rate for Payer: Signature Care EPO |
$820.44
|
| Rate for Payer: Signature Care PPO |
$869.86
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$840.21
|
| Rate for Payer: United Healthcare Commercial |
$778.92
|
| Rate for Payer: United Healthcare Medicare |
$316.31
|
|
|
HC HEMACHROM MUTATION HEREDITARY
|
Facility
|
IP
|
$988.48
|
|
|
Service Code
|
CPT 81256
|
| Hospital Charge Code |
63001438
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$741.36 |
| Max. Negotiated Rate |
$919.29 |
| Rate for Payer: Aetna Commercial |
$854.05
|
| Rate for Payer: Cash Price |
$593.09
|
| Rate for Payer: Cigna All Commercial |
$853.06
|
| Rate for Payer: CORVEL All Commercial |
$919.29
|
| Rate for Payer: Coventry All Commercial |
$869.86
|
| Rate for Payer: Encore All Commercial |
$909.90
|
| Rate for Payer: Frontpath All Commercial |
$909.40
|
| Rate for Payer: Humana ChoiceCare |
$853.75
|
| Rate for Payer: Lutheran Preferred All Commercial |
$889.63
|
| Rate for Payer: PHCS All Commercial |
$741.36
|
| Rate for Payer: PHP All Commercial |
$749.66
|
| Rate for Payer: Sagamore Health Network All Products |
$763.11
|
| Rate for Payer: Signature Care EPO |
$820.44
|
| Rate for Payer: Signature Care PPO |
$869.86
|
| Rate for Payer: United Healthcare Commercial |
$778.92
|
|
