|
HC NEEDLE TUOHY 20X3.5
|
Facility
|
IP
|
$47.42
|
|
| Hospital Charge Code |
41607083
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$35.56 |
| Max. Negotiated Rate |
$44.10 |
| Rate for Payer: Aetna Commercial |
$40.97
|
| Rate for Payer: Cash Price |
$28.45
|
| Rate for Payer: Cigna All Commercial |
$40.92
|
| Rate for Payer: CORVEL All Commercial |
$44.10
|
| Rate for Payer: Coventry All Commercial |
$41.73
|
| Rate for Payer: Encore All Commercial |
$43.65
|
| Rate for Payer: Frontpath All Commercial |
$43.63
|
| Rate for Payer: Humana ChoiceCare |
$40.96
|
| Rate for Payer: Lutheran Preferred All Commercial |
$42.68
|
| Rate for Payer: PHCS All Commercial |
$35.56
|
| Rate for Payer: PHP All Commercial |
$35.96
|
| Rate for Payer: Sagamore Health Network All Products |
$36.61
|
| Rate for Payer: Signature Care EPO |
$39.36
|
| Rate for Payer: Signature Care PPO |
$41.73
|
| Rate for Payer: United Healthcare Commercial |
$37.37
|
|
|
HC NEEDLE TUOHY 20X3.5
|
Facility
|
OP
|
$47.42
|
|
| Hospital Charge Code |
41607083
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$14.70 |
| Max. Negotiated Rate |
$44.10 |
| Rate for Payer: Aetna Commercial |
$40.02
|
| Rate for Payer: Aetna Medicare |
$15.17
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$31.20
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$14.70
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$27.23
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$29.64
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$31.20
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$17.45
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$16.69
|
| Rate for Payer: Cash Price |
$28.45
|
| Rate for Payer: Cash Price |
$28.45
|
| Rate for Payer: Centivo All Commercial |
$25.80
|
| Rate for Payer: Cigna All Commercial |
$40.92
|
| Rate for Payer: CORVEL All Commercial |
$44.10
|
| Rate for Payer: Coventry All Commercial |
$41.73
|
| Rate for Payer: Encore All Commercial |
$43.65
|
| Rate for Payer: Frontpath All Commercial |
$43.63
|
| Rate for Payer: Humana ChoiceCare |
$40.96
|
| Rate for Payer: Humana Medicare |
$15.17
|
| Rate for Payer: Lucent All Commercial |
$25.80
|
| Rate for Payer: Lutheran Preferred All Commercial |
$42.68
|
| Rate for Payer: Managed Health Services Medicaid |
$31.20
|
| Rate for Payer: MDWise Medicaid |
$31.20
|
| Rate for Payer: PHCS All Commercial |
$35.56
|
| Rate for Payer: PHP All Commercial |
$35.96
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$18.49
|
| Rate for Payer: Sagamore Health Network All Products |
$36.61
|
| Rate for Payer: Signature Care EPO |
$39.36
|
| Rate for Payer: Signature Care PPO |
$41.73
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$40.31
|
| Rate for Payer: United Healthcare Commercial |
$37.37
|
| Rate for Payer: United Healthcare Medicare |
$15.17
|
|
|
HC NEEDLE TUOHY 20X6
|
Facility
|
OP
|
$61.61
|
|
| Hospital Charge Code |
41607093
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$19.10 |
| Max. Negotiated Rate |
$57.30 |
| Rate for Payer: Aetna Commercial |
$52.00
|
| Rate for Payer: Aetna Medicare |
$19.72
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$31.20
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$19.10
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$35.38
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$38.51
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$31.20
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$22.67
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$21.69
|
| Rate for Payer: Cash Price |
$36.97
|
| Rate for Payer: Cash Price |
$36.97
|
| Rate for Payer: Centivo All Commercial |
$33.52
|
| Rate for Payer: Cigna All Commercial |
$53.17
|
| Rate for Payer: CORVEL All Commercial |
$57.30
|
| Rate for Payer: Coventry All Commercial |
$54.22
|
| Rate for Payer: Encore All Commercial |
$56.71
|
| Rate for Payer: Frontpath All Commercial |
$56.68
|
| Rate for Payer: Humana ChoiceCare |
$53.21
|
| Rate for Payer: Humana Medicare |
$19.72
|
| Rate for Payer: Lucent All Commercial |
$33.52
|
| Rate for Payer: Lutheran Preferred All Commercial |
$55.45
|
| Rate for Payer: Managed Health Services Medicaid |
$31.20
|
| Rate for Payer: MDWise Medicaid |
$31.20
|
| Rate for Payer: PHCS All Commercial |
$46.21
|
| Rate for Payer: PHP All Commercial |
$46.73
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$24.03
|
| Rate for Payer: Sagamore Health Network All Products |
$47.56
|
| Rate for Payer: Signature Care EPO |
$51.14
|
| Rate for Payer: Signature Care PPO |
$54.22
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$52.37
|
| Rate for Payer: United Healthcare Commercial |
$48.55
|
| Rate for Payer: United Healthcare Medicare |
$19.72
|
|
|
HC NEEDLE TUOHY 20X6
|
Facility
|
IP
|
$61.61
|
|
| Hospital Charge Code |
41607093
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$46.21 |
| Max. Negotiated Rate |
$57.30 |
| Rate for Payer: Aetna Commercial |
$53.23
|
| Rate for Payer: Cash Price |
$36.97
|
| Rate for Payer: Cigna All Commercial |
$53.17
|
| Rate for Payer: CORVEL All Commercial |
$57.30
|
| Rate for Payer: Coventry All Commercial |
$54.22
|
| Rate for Payer: Encore All Commercial |
$56.71
|
| Rate for Payer: Frontpath All Commercial |
$56.68
|
| Rate for Payer: Humana ChoiceCare |
$53.21
|
| Rate for Payer: Lutheran Preferred All Commercial |
$55.45
|
| Rate for Payer: PHCS All Commercial |
$46.21
|
| Rate for Payer: PHP All Commercial |
$46.73
|
| Rate for Payer: Sagamore Health Network All Products |
$47.56
|
| Rate for Payer: Signature Care EPO |
$51.14
|
| Rate for Payer: Signature Care PPO |
$54.22
|
| Rate for Payer: United Healthcare Commercial |
$48.55
|
|
|
HC NEEDLE WHITACRE 25G X 3 1/2 IN
|
Facility
|
OP
|
$49.36
|
|
| Hospital Charge Code |
41602305
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$15.30 |
| Max. Negotiated Rate |
$45.90 |
| Rate for Payer: Aetna Commercial |
$41.66
|
| Rate for Payer: Aetna Medicare |
$15.80
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$31.20
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$15.30
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$28.35
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$30.85
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$31.20
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$18.16
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$17.37
|
| Rate for Payer: Cash Price |
$29.62
|
| Rate for Payer: Cash Price |
$29.62
|
| Rate for Payer: Centivo All Commercial |
$26.85
|
| Rate for Payer: Cigna All Commercial |
$42.60
|
| Rate for Payer: CORVEL All Commercial |
$45.90
|
| Rate for Payer: Coventry All Commercial |
$43.44
|
| Rate for Payer: Encore All Commercial |
$45.44
|
| Rate for Payer: Frontpath All Commercial |
$45.41
|
| Rate for Payer: Humana ChoiceCare |
$42.63
|
| Rate for Payer: Humana Medicare |
$15.80
|
| Rate for Payer: Lucent All Commercial |
$26.85
|
| Rate for Payer: Lutheran Preferred All Commercial |
$44.42
|
| Rate for Payer: Managed Health Services Medicaid |
$31.20
|
| Rate for Payer: MDWise Medicaid |
$31.20
|
| Rate for Payer: PHCS All Commercial |
$37.02
|
| Rate for Payer: PHP All Commercial |
$37.43
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$19.25
|
| Rate for Payer: Sagamore Health Network All Products |
$38.11
|
| Rate for Payer: Signature Care EPO |
$40.97
|
| Rate for Payer: Signature Care PPO |
$43.44
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$41.96
|
| Rate for Payer: United Healthcare Commercial |
$38.90
|
| Rate for Payer: United Healthcare Medicare |
$15.80
|
|
|
HC NEEDLE WHITACRE 25G X 3 1/2 IN
|
Facility
|
IP
|
$49.36
|
|
| Hospital Charge Code |
41602305
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$37.02 |
| Max. Negotiated Rate |
$45.90 |
| Rate for Payer: Aetna Commercial |
$42.65
|
| Rate for Payer: Cash Price |
$29.62
|
| Rate for Payer: Cigna All Commercial |
$42.60
|
| Rate for Payer: CORVEL All Commercial |
$45.90
|
| Rate for Payer: Coventry All Commercial |
$43.44
|
| Rate for Payer: Encore All Commercial |
$45.44
|
| Rate for Payer: Frontpath All Commercial |
$45.41
|
| Rate for Payer: Humana ChoiceCare |
$42.63
|
| Rate for Payer: Lutheran Preferred All Commercial |
$44.42
|
| Rate for Payer: PHCS All Commercial |
$37.02
|
| Rate for Payer: PHP All Commercial |
$37.43
|
| Rate for Payer: Sagamore Health Network All Products |
$38.11
|
| Rate for Payer: Signature Care EPO |
$40.97
|
| Rate for Payer: Signature Care PPO |
$43.44
|
| Rate for Payer: United Healthcare Commercial |
$38.90
|
|
|
HC NEG PRESS WOUND TX < 50 CM
|
Facility
|
IP
|
$250.93
|
|
|
Service Code
|
CPT 97605
|
| Hospital Charge Code |
1897605
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$188.20 |
| Max. Negotiated Rate |
$233.36 |
| Rate for Payer: Aetna Commercial |
$216.80
|
| Rate for Payer: Cash Price |
$150.56
|
| Rate for Payer: Cigna All Commercial |
$216.55
|
| Rate for Payer: CORVEL All Commercial |
$233.36
|
| Rate for Payer: Coventry All Commercial |
$220.82
|
| Rate for Payer: Encore All Commercial |
$230.98
|
| Rate for Payer: Frontpath All Commercial |
$230.86
|
| Rate for Payer: Humana ChoiceCare |
$216.73
|
| Rate for Payer: Lutheran Preferred All Commercial |
$225.84
|
| Rate for Payer: PHCS All Commercial |
$188.20
|
| Rate for Payer: PHP All Commercial |
$190.31
|
| Rate for Payer: Sagamore Health Network All Products |
$193.72
|
| Rate for Payer: Signature Care EPO |
$208.27
|
| Rate for Payer: Signature Care PPO |
$220.82
|
| Rate for Payer: United Healthcare Commercial |
$197.73
|
|
|
HC NEG PRESS WOUND TX < 50 CM
|
Facility
|
OP
|
$250.93
|
|
|
Service Code
|
CPT 97605
|
| Hospital Charge Code |
1897605
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$77.79 |
| Max. Negotiated Rate |
$233.36 |
| Rate for Payer: Aetna Commercial |
$211.78
|
| Rate for Payer: Aetna Medicare |
$80.30
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$97.73
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$77.79
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$144.11
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$156.86
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$97.73
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$92.34
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$88.33
|
| Rate for Payer: Cash Price |
$150.56
|
| Rate for Payer: Cash Price |
$150.56
|
| Rate for Payer: Centivo All Commercial |
$136.51
|
| Rate for Payer: Cigna All Commercial |
$216.55
|
| Rate for Payer: CORVEL All Commercial |
$233.36
|
| Rate for Payer: Coventry All Commercial |
$220.82
|
| Rate for Payer: Encore All Commercial |
$230.98
|
| Rate for Payer: Frontpath All Commercial |
$230.86
|
| Rate for Payer: Humana ChoiceCare |
$216.73
|
| Rate for Payer: Humana Medicare |
$80.30
|
| Rate for Payer: Lucent All Commercial |
$136.51
|
| Rate for Payer: Lutheran Preferred All Commercial |
$225.84
|
| Rate for Payer: Managed Health Services Medicaid |
$97.73
|
| Rate for Payer: MDWise Medicaid |
$97.73
|
| Rate for Payer: PHCS All Commercial |
$188.20
|
| Rate for Payer: PHP All Commercial |
$190.31
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$97.86
|
| Rate for Payer: Sagamore Health Network All Products |
$193.72
|
| Rate for Payer: Signature Care EPO |
$208.27
|
| Rate for Payer: Signature Care PPO |
$220.82
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$213.29
|
| Rate for Payer: United Healthcare Commercial |
$197.73
|
| Rate for Payer: United Healthcare Medicare |
$80.30
|
|
|
HC NEG PRESS WOUND TX > 50 CM
|
Facility
|
IP
|
$302.60
|
|
|
Service Code
|
CPT 97606
|
| Hospital Charge Code |
1897606
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$226.95 |
| Max. Negotiated Rate |
$281.42 |
| Rate for Payer: Aetna Commercial |
$261.45
|
| Rate for Payer: Cash Price |
$181.56
|
| Rate for Payer: Cigna All Commercial |
$261.14
|
| Rate for Payer: CORVEL All Commercial |
$281.42
|
| Rate for Payer: Coventry All Commercial |
$266.29
|
| Rate for Payer: Encore All Commercial |
$278.54
|
| Rate for Payer: Frontpath All Commercial |
$278.39
|
| Rate for Payer: Humana ChoiceCare |
$261.36
|
| Rate for Payer: Lutheran Preferred All Commercial |
$272.34
|
| Rate for Payer: PHCS All Commercial |
$226.95
|
| Rate for Payer: PHP All Commercial |
$229.49
|
| Rate for Payer: Sagamore Health Network All Products |
$233.61
|
| Rate for Payer: Signature Care EPO |
$251.16
|
| Rate for Payer: Signature Care PPO |
$266.29
|
| Rate for Payer: United Healthcare Commercial |
$238.45
|
|
|
HC NEG PRESS WOUND TX > 50 CM
|
Facility
|
OP
|
$302.60
|
|
|
Service Code
|
CPT 97606
|
| Hospital Charge Code |
1897606
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$93.81 |
| Max. Negotiated Rate |
$281.42 |
| Rate for Payer: Aetna Commercial |
$255.39
|
| Rate for Payer: Aetna Medicare |
$96.83
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$97.73
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$93.81
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$173.78
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$189.16
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$97.73
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$111.36
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$106.52
|
| Rate for Payer: Cash Price |
$181.56
|
| Rate for Payer: Cash Price |
$181.56
|
| Rate for Payer: Centivo All Commercial |
$164.61
|
| Rate for Payer: Cigna All Commercial |
$261.14
|
| Rate for Payer: CORVEL All Commercial |
$281.42
|
| Rate for Payer: Coventry All Commercial |
$266.29
|
| Rate for Payer: Encore All Commercial |
$278.54
|
| Rate for Payer: Frontpath All Commercial |
$278.39
|
| Rate for Payer: Humana ChoiceCare |
$261.36
|
| Rate for Payer: Humana Medicare |
$96.83
|
| Rate for Payer: Lucent All Commercial |
$164.61
|
| Rate for Payer: Lutheran Preferred All Commercial |
$272.34
|
| Rate for Payer: Managed Health Services Medicaid |
$97.73
|
| Rate for Payer: MDWise Medicaid |
$97.73
|
| Rate for Payer: PHCS All Commercial |
$226.95
|
| Rate for Payer: PHP All Commercial |
$229.49
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$118.01
|
| Rate for Payer: Sagamore Health Network All Products |
$233.61
|
| Rate for Payer: Signature Care EPO |
$251.16
|
| Rate for Payer: Signature Care PPO |
$266.29
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$257.21
|
| Rate for Payer: United Healthcare Commercial |
$238.45
|
| Rate for Payer: United Healthcare Medicare |
$96.83
|
|
|
HC NEPHELOMETRY ANALYTE EA
|
Facility
|
IP
|
$170.35
|
|
|
Service Code
|
CPT 83883
|
| Hospital Charge Code |
63001640
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$127.76 |
| Max. Negotiated Rate |
$158.43 |
| Rate for Payer: Aetna Commercial |
$147.18
|
| Rate for Payer: Cash Price |
$102.21
|
| Rate for Payer: Cigna All Commercial |
$147.01
|
| Rate for Payer: CORVEL All Commercial |
$158.43
|
| Rate for Payer: Coventry All Commercial |
$149.91
|
| Rate for Payer: Encore All Commercial |
$156.81
|
| Rate for Payer: Frontpath All Commercial |
$156.72
|
| Rate for Payer: Humana ChoiceCare |
$147.13
|
| Rate for Payer: Lutheran Preferred All Commercial |
$153.31
|
| Rate for Payer: PHCS All Commercial |
$127.76
|
| Rate for Payer: PHP All Commercial |
$129.19
|
| Rate for Payer: Sagamore Health Network All Products |
$131.51
|
| Rate for Payer: Signature Care EPO |
$141.39
|
| Rate for Payer: Signature Care PPO |
$149.91
|
| Rate for Payer: United Healthcare Commercial |
$134.24
|
|
|
HC NEPHELOMETRY ANALYTE EA
|
Facility
|
OP
|
$170.35
|
|
|
Service Code
|
CPT 83883
|
| Hospital Charge Code |
63001640
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.60 |
| Max. Negotiated Rate |
$158.43 |
| Rate for Payer: Aetna Commercial |
$143.78
|
| Rate for Payer: Aetna Medicare |
$54.51
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$13.60
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$52.81
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$78.29
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$78.29
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$13.60
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$62.69
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$59.96
|
| Rate for Payer: Cash Price |
$102.21
|
| Rate for Payer: Cash Price |
$102.21
|
| Rate for Payer: Centivo All Commercial |
$92.67
|
| Rate for Payer: Cigna All Commercial |
$147.01
|
| Rate for Payer: CORVEL All Commercial |
$158.43
|
| Rate for Payer: Coventry All Commercial |
$149.91
|
| Rate for Payer: Encore All Commercial |
$156.81
|
| Rate for Payer: Frontpath All Commercial |
$156.72
|
| Rate for Payer: Humana ChoiceCare |
$147.13
|
| Rate for Payer: Humana Medicare |
$54.51
|
| Rate for Payer: Lucent All Commercial |
$92.67
|
| Rate for Payer: Lutheran Preferred All Commercial |
$153.31
|
| Rate for Payer: Managed Health Services Medicaid |
$13.60
|
| Rate for Payer: MDWise Medicaid |
$13.60
|
| Rate for Payer: PHCS All Commercial |
$127.76
|
| Rate for Payer: PHP All Commercial |
$129.19
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$66.44
|
| Rate for Payer: Sagamore Health Network All Products |
$131.51
|
| Rate for Payer: Signature Care EPO |
$141.39
|
| Rate for Payer: Signature Care PPO |
$149.91
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$144.80
|
| Rate for Payer: United Healthcare Commercial |
$134.24
|
| Rate for Payer: United Healthcare Medicare |
$54.51
|
|
|
HC NEUROMUSCLE RE-ED/15 MIN-OT
|
Facility
|
IP
|
$137.53
|
|
|
Service Code
|
CPT 97112 GO
|
| Hospital Charge Code |
1738041
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$103.15 |
| Max. Negotiated Rate |
$127.90 |
| Rate for Payer: Aetna Commercial |
$118.83
|
| Rate for Payer: Cash Price |
$82.52
|
| Rate for Payer: Cigna All Commercial |
$118.69
|
| Rate for Payer: CORVEL All Commercial |
$127.90
|
| Rate for Payer: Coventry All Commercial |
$121.03
|
| Rate for Payer: Encore All Commercial |
$126.60
|
| Rate for Payer: Frontpath All Commercial |
$126.53
|
| Rate for Payer: Humana ChoiceCare |
$118.78
|
| Rate for Payer: Lutheran Preferred All Commercial |
$123.78
|
| Rate for Payer: PHCS All Commercial |
$103.15
|
| Rate for Payer: PHP All Commercial |
$104.30
|
| Rate for Payer: Sagamore Health Network All Products |
$106.17
|
| Rate for Payer: Signature Care EPO |
$114.15
|
| Rate for Payer: Signature Care PPO |
$121.03
|
| Rate for Payer: United Healthcare Commercial |
$108.37
|
|
|
HC NEUROMUSCLE RE-ED/15 MIN-OT
|
Facility
|
OP
|
$137.53
|
|
|
Service Code
|
CPT 97112 GO
|
| Hospital Charge Code |
1738041
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$42.63 |
| Max. Negotiated Rate |
$127.90 |
| Rate for Payer: Aetna Commercial |
$116.08
|
| Rate for Payer: Aetna Medicare |
$44.01
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$47.81
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$42.63
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$78.98
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$85.97
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$47.81
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$50.61
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$48.41
|
| Rate for Payer: Cash Price |
$82.52
|
| Rate for Payer: Cash Price |
$82.52
|
| Rate for Payer: Centivo All Commercial |
$74.82
|
| Rate for Payer: Cigna All Commercial |
$118.69
|
| Rate for Payer: CORVEL All Commercial |
$127.90
|
| Rate for Payer: Coventry All Commercial |
$121.03
|
| Rate for Payer: Encore All Commercial |
$126.60
|
| Rate for Payer: Frontpath All Commercial |
$126.53
|
| Rate for Payer: Humana ChoiceCare |
$118.78
|
| Rate for Payer: Humana Medicare |
$44.01
|
| Rate for Payer: Lucent All Commercial |
$74.82
|
| Rate for Payer: Lutheran Preferred All Commercial |
$123.78
|
| Rate for Payer: Managed Health Services Medicaid |
$47.81
|
| Rate for Payer: MDWise Medicaid |
$47.81
|
| Rate for Payer: PHCS All Commercial |
$103.15
|
| Rate for Payer: PHP All Commercial |
$104.30
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$53.64
|
| Rate for Payer: Sagamore Health Network All Products |
$106.17
|
| Rate for Payer: Signature Care EPO |
$114.15
|
| Rate for Payer: Signature Care PPO |
$121.03
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$116.90
|
| Rate for Payer: United Healthcare Commercial |
$108.37
|
| Rate for Payer: United Healthcare Medicare |
$44.01
|
|
|
HC NEUROMUSCLE RE-ED/15 MIN-PT
|
Facility
|
IP
|
$137.53
|
|
|
Service Code
|
CPT 97112 GP
|
| Hospital Charge Code |
1728055
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$103.15 |
| Max. Negotiated Rate |
$127.90 |
| Rate for Payer: Aetna Commercial |
$118.83
|
| Rate for Payer: Cash Price |
$82.52
|
| Rate for Payer: Cigna All Commercial |
$118.69
|
| Rate for Payer: CORVEL All Commercial |
$127.90
|
| Rate for Payer: Coventry All Commercial |
$121.03
|
| Rate for Payer: Encore All Commercial |
$126.60
|
| Rate for Payer: Frontpath All Commercial |
$126.53
|
| Rate for Payer: Humana ChoiceCare |
$118.78
|
| Rate for Payer: Lutheran Preferred All Commercial |
$123.78
|
| Rate for Payer: PHCS All Commercial |
$103.15
|
| Rate for Payer: PHP All Commercial |
$104.30
|
| Rate for Payer: Sagamore Health Network All Products |
$106.17
|
| Rate for Payer: Signature Care EPO |
$114.15
|
| Rate for Payer: Signature Care PPO |
$121.03
|
| Rate for Payer: United Healthcare Commercial |
$108.37
|
|
|
HC NEUROMUSCLE RE-ED/15 MIN-PT
|
Facility
|
OP
|
$137.53
|
|
|
Service Code
|
CPT 97112 GP
|
| Hospital Charge Code |
1728055
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$42.63 |
| Max. Negotiated Rate |
$127.90 |
| Rate for Payer: Aetna Commercial |
$116.08
|
| Rate for Payer: Aetna Medicare |
$44.01
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$47.81
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$42.63
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$78.98
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$85.97
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$47.81
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$50.61
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$48.41
|
| Rate for Payer: Cash Price |
$82.52
|
| Rate for Payer: Cash Price |
$82.52
|
| Rate for Payer: Centivo All Commercial |
$74.82
|
| Rate for Payer: Cigna All Commercial |
$118.69
|
| Rate for Payer: CORVEL All Commercial |
$127.90
|
| Rate for Payer: Coventry All Commercial |
$121.03
|
| Rate for Payer: Encore All Commercial |
$126.60
|
| Rate for Payer: Frontpath All Commercial |
$126.53
|
| Rate for Payer: Humana ChoiceCare |
$118.78
|
| Rate for Payer: Humana Medicare |
$44.01
|
| Rate for Payer: Lucent All Commercial |
$74.82
|
| Rate for Payer: Lutheran Preferred All Commercial |
$123.78
|
| Rate for Payer: Managed Health Services Medicaid |
$47.81
|
| Rate for Payer: MDWise Medicaid |
$47.81
|
| Rate for Payer: PHCS All Commercial |
$103.15
|
| Rate for Payer: PHP All Commercial |
$104.30
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$53.64
|
| Rate for Payer: Sagamore Health Network All Products |
$106.17
|
| Rate for Payer: Signature Care EPO |
$114.15
|
| Rate for Payer: Signature Care PPO |
$121.03
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$116.90
|
| Rate for Payer: United Healthcare Commercial |
$108.37
|
| Rate for Payer: United Healthcare Medicare |
$44.01
|
|
|
HC NEWBORN CARE
|
Facility
|
IP
|
$1,060.80
|
|
| Hospital Charge Code |
10010028
|
|
Hospital Revenue Code
|
170
|
| Min. Negotiated Rate |
$795.60 |
| Max. Negotiated Rate |
$6,636.80 |
| Rate for Payer: Aetna Commercial |
$916.53
|
| Rate for Payer: Aetna Medicare |
$3,904.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$3,864.00
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$4,489.60
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$4,294.40
|
| Rate for Payer: Cash Price |
$636.48
|
| Rate for Payer: Cash Price |
$636.48
|
| Rate for Payer: Centivo All Commercial |
$6,636.80
|
| Rate for Payer: Cigna All Commercial |
$915.47
|
| Rate for Payer: CORVEL All Commercial |
$986.54
|
| Rate for Payer: Coventry All Commercial |
$933.50
|
| Rate for Payer: Encore All Commercial |
$976.47
|
| Rate for Payer: Frontpath All Commercial |
$975.94
|
| Rate for Payer: Humana ChoiceCare |
$916.21
|
| Rate for Payer: Humana Medicare |
$3,904.00
|
| Rate for Payer: Lucent All Commercial |
$6,636.80
|
| Rate for Payer: Lutheran Preferred All Commercial |
$954.72
|
| Rate for Payer: PHCS All Commercial |
$795.60
|
| Rate for Payer: PHP All Commercial |
$804.51
|
| Rate for Payer: Sagamore Health Network All Products |
$818.94
|
| Rate for Payer: Signature Care EPO |
$880.46
|
| Rate for Payer: Signature Care PPO |
$933.50
|
| Rate for Payer: United Healthcare Commercial |
$835.91
|
| Rate for Payer: United Healthcare Medicare |
$3,904.00
|
|
|
HC NEWBORN HEARING AEP SCR AUDITORY POTENTIAL
|
Facility
|
OP
|
$344.76
|
|
|
Service Code
|
CPT 92650
|
| Hospital Charge Code |
1012650
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$47.81 |
| Max. Negotiated Rate |
$320.63 |
| Rate for Payer: Aetna Commercial |
$290.98
|
| Rate for Payer: Aetna Medicare |
$110.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$47.81
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$106.88
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$198.00
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$215.51
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$47.81
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$126.87
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$121.36
|
| Rate for Payer: Cash Price |
$206.86
|
| Rate for Payer: Cash Price |
$206.86
|
| Rate for Payer: Centivo All Commercial |
$187.55
|
| Rate for Payer: Cigna All Commercial |
$297.53
|
| Rate for Payer: CORVEL All Commercial |
$320.63
|
| Rate for Payer: Coventry All Commercial |
$303.39
|
| Rate for Payer: Encore All Commercial |
$317.35
|
| Rate for Payer: Frontpath All Commercial |
$317.18
|
| Rate for Payer: Humana ChoiceCare |
$297.77
|
| Rate for Payer: Humana Medicare |
$110.32
|
| Rate for Payer: Lucent All Commercial |
$187.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$310.28
|
| Rate for Payer: Managed Health Services Medicaid |
$47.81
|
| Rate for Payer: MDWise Medicaid |
$47.81
|
| Rate for Payer: PHCS All Commercial |
$258.57
|
| Rate for Payer: PHP All Commercial |
$261.47
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$134.46
|
| Rate for Payer: Sagamore Health Network All Products |
$266.15
|
| Rate for Payer: Signature Care EPO |
$286.15
|
| Rate for Payer: Signature Care PPO |
$303.39
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$293.05
|
| Rate for Payer: United Healthcare Commercial |
$271.67
|
| Rate for Payer: United Healthcare Medicare |
$110.32
|
|
|
HC NEWBORN HEARING AEP SCR AUDITORY POTENTIAL
|
Facility
|
IP
|
$344.76
|
|
|
Service Code
|
CPT 92650
|
| Hospital Charge Code |
1012650
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$258.57 |
| Max. Negotiated Rate |
$320.63 |
| Rate for Payer: Aetna Commercial |
$297.87
|
| Rate for Payer: Cash Price |
$206.86
|
| Rate for Payer: Cigna All Commercial |
$297.53
|
| Rate for Payer: CORVEL All Commercial |
$320.63
|
| Rate for Payer: Coventry All Commercial |
$303.39
|
| Rate for Payer: Encore All Commercial |
$317.35
|
| Rate for Payer: Frontpath All Commercial |
$317.18
|
| Rate for Payer: Humana ChoiceCare |
$297.77
|
| Rate for Payer: Lutheran Preferred All Commercial |
$310.28
|
| Rate for Payer: PHCS All Commercial |
$258.57
|
| Rate for Payer: PHP All Commercial |
$261.47
|
| Rate for Payer: Sagamore Health Network All Products |
$266.15
|
| Rate for Payer: Signature Care EPO |
$286.15
|
| Rate for Payer: Signature Care PPO |
$303.39
|
| Rate for Payer: United Healthcare Commercial |
$271.67
|
|
|
HC NEWBORN RESUSCITATION
|
Facility
|
IP
|
$1,310.70
|
|
|
Service Code
|
CPT 99465
|
| Hospital Charge Code |
1709440
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$983.02 |
| Max. Negotiated Rate |
$1,218.95 |
| Rate for Payer: Aetna Commercial |
$1,132.44
|
| Rate for Payer: Cash Price |
$786.42
|
| Rate for Payer: Cigna All Commercial |
$1,131.13
|
| Rate for Payer: CORVEL All Commercial |
$1,218.95
|
| Rate for Payer: Coventry All Commercial |
$1,153.42
|
| Rate for Payer: Encore All Commercial |
$1,206.50
|
| Rate for Payer: Frontpath All Commercial |
$1,205.84
|
| Rate for Payer: Humana ChoiceCare |
$1,132.05
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,179.63
|
| Rate for Payer: PHCS All Commercial |
$983.02
|
| Rate for Payer: PHP All Commercial |
$994.03
|
| Rate for Payer: Sagamore Health Network All Products |
$1,011.86
|
| Rate for Payer: Signature Care EPO |
$1,087.88
|
| Rate for Payer: Signature Care PPO |
$1,153.42
|
| Rate for Payer: United Healthcare Commercial |
$1,032.83
|
|
|
HC NEWBORN RESUSCITATION
|
Facility
|
OP
|
$1,310.70
|
|
|
Service Code
|
CPT 99465
|
| Hospital Charge Code |
1709440
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$166.32 |
| Max. Negotiated Rate |
$1,218.95 |
| Rate for Payer: Aetna Commercial |
$1,106.23
|
| Rate for Payer: Aetna Medicare |
$419.42
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$166.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$406.32
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$752.74
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$819.32
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$166.32
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$482.34
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$461.37
|
| Rate for Payer: Cash Price |
$786.42
|
| Rate for Payer: Cash Price |
$786.42
|
| Rate for Payer: Centivo All Commercial |
$713.02
|
| Rate for Payer: Cigna All Commercial |
$1,131.13
|
| Rate for Payer: CORVEL All Commercial |
$1,218.95
|
| Rate for Payer: Coventry All Commercial |
$1,153.42
|
| Rate for Payer: Encore All Commercial |
$1,206.50
|
| Rate for Payer: Frontpath All Commercial |
$1,205.84
|
| Rate for Payer: Humana ChoiceCare |
$1,132.05
|
| Rate for Payer: Humana Medicare |
$419.42
|
| Rate for Payer: Lucent All Commercial |
$713.02
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,179.63
|
| Rate for Payer: Managed Health Services Medicaid |
$166.32
|
| Rate for Payer: MDWise Medicaid |
$166.32
|
| Rate for Payer: PHCS All Commercial |
$983.02
|
| Rate for Payer: PHP All Commercial |
$994.03
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$511.17
|
| Rate for Payer: Sagamore Health Network All Products |
$1,011.86
|
| Rate for Payer: Signature Care EPO |
$1,087.88
|
| Rate for Payer: Signature Care PPO |
$1,153.42
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,114.10
|
| Rate for Payer: United Healthcare Commercial |
$1,032.83
|
| Rate for Payer: United Healthcare Medicare |
$419.42
|
|
|
HC NEWBORN SCREEN (PKU)
|
Facility
|
OP
|
$214.60
|
|
|
Service Code
|
CPT 84030
|
| Hospital Charge Code |
63001653
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.50 |
| Max. Negotiated Rate |
$199.58 |
| Rate for Payer: Aetna Commercial |
$181.12
|
| Rate for Payer: Aetna Medicare |
$68.67
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$5.50
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$66.53
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$98.63
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$98.63
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$5.50
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$78.97
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$75.54
|
| Rate for Payer: Cash Price |
$128.76
|
| Rate for Payer: Cash Price |
$128.76
|
| Rate for Payer: Centivo All Commercial |
$116.74
|
| Rate for Payer: Cigna All Commercial |
$185.20
|
| Rate for Payer: CORVEL All Commercial |
$199.58
|
| Rate for Payer: Coventry All Commercial |
$188.85
|
| Rate for Payer: Encore All Commercial |
$197.54
|
| Rate for Payer: Frontpath All Commercial |
$197.43
|
| Rate for Payer: Humana ChoiceCare |
$185.35
|
| Rate for Payer: Humana Medicare |
$68.67
|
| Rate for Payer: Lucent All Commercial |
$116.74
|
| Rate for Payer: Lutheran Preferred All Commercial |
$193.14
|
| Rate for Payer: Managed Health Services Medicaid |
$5.50
|
| Rate for Payer: MDWise Medicaid |
$5.50
|
| Rate for Payer: PHCS All Commercial |
$160.95
|
| Rate for Payer: PHP All Commercial |
$162.75
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$83.69
|
| Rate for Payer: Sagamore Health Network All Products |
$165.67
|
| Rate for Payer: Signature Care EPO |
$178.12
|
| Rate for Payer: Signature Care PPO |
$188.85
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$182.41
|
| Rate for Payer: United Healthcare Commercial |
$169.10
|
| Rate for Payer: United Healthcare Medicare |
$68.67
|
|
|
HC NEWBORN SCREEN (PKU)
|
Facility
|
IP
|
$214.60
|
|
|
Service Code
|
CPT 84030
|
| Hospital Charge Code |
63001653
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$160.95 |
| Max. Negotiated Rate |
$199.58 |
| Rate for Payer: Aetna Commercial |
$185.41
|
| Rate for Payer: Cash Price |
$128.76
|
| Rate for Payer: Cigna All Commercial |
$185.20
|
| Rate for Payer: CORVEL All Commercial |
$199.58
|
| Rate for Payer: Coventry All Commercial |
$188.85
|
| Rate for Payer: Encore All Commercial |
$197.54
|
| Rate for Payer: Frontpath All Commercial |
$197.43
|
| Rate for Payer: Humana ChoiceCare |
$185.35
|
| Rate for Payer: Lutheran Preferred All Commercial |
$193.14
|
| Rate for Payer: PHCS All Commercial |
$160.95
|
| Rate for Payer: PHP All Commercial |
$162.75
|
| Rate for Payer: Sagamore Health Network All Products |
$165.67
|
| Rate for Payer: Signature Care EPO |
$178.12
|
| Rate for Payer: Signature Care PPO |
$188.85
|
| Rate for Payer: United Healthcare Commercial |
$169.10
|
|
|
HC NFCT DS BV&VAGINITIS AMP PRB
|
Facility
|
OP
|
$398.50
|
|
|
Service Code
|
CPT 81515
|
| Hospital Charge Code |
63000352
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$123.53 |
| Max. Negotiated Rate |
$370.61 |
| Rate for Payer: Aetna Commercial |
$336.33
|
| Rate for Payer: Aetna Medicare |
$127.52
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$262.99
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$123.53
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$183.15
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$183.15
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$262.99
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$146.65
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$140.27
|
| Rate for Payer: Cash Price |
$239.10
|
| Rate for Payer: Cash Price |
$239.10
|
| Rate for Payer: Centivo All Commercial |
$216.78
|
| Rate for Payer: Cigna All Commercial |
$343.91
|
| Rate for Payer: CORVEL All Commercial |
$370.61
|
| Rate for Payer: Coventry All Commercial |
$350.68
|
| Rate for Payer: Encore All Commercial |
$366.82
|
| Rate for Payer: Frontpath All Commercial |
$366.62
|
| Rate for Payer: Humana ChoiceCare |
$344.18
|
| Rate for Payer: Humana Medicare |
$127.52
|
| Rate for Payer: Lucent All Commercial |
$216.78
|
| Rate for Payer: Lutheran Preferred All Commercial |
$358.65
|
| Rate for Payer: Managed Health Services Medicaid |
$262.99
|
| Rate for Payer: MDWise Medicaid |
$262.99
|
| Rate for Payer: PHCS All Commercial |
$298.88
|
| Rate for Payer: PHP All Commercial |
$302.22
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$155.41
|
| Rate for Payer: Sagamore Health Network All Products |
$307.64
|
| Rate for Payer: Signature Care EPO |
$330.75
|
| Rate for Payer: Signature Care PPO |
$350.68
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$338.73
|
| Rate for Payer: United Healthcare Commercial |
$314.02
|
| Rate for Payer: United Healthcare Medicare |
$127.52
|
|
|
HC NFCT DS BV&VAGINITIS AMP PRB
|
Facility
|
IP
|
$398.50
|
|
|
Service Code
|
CPT 81515
|
| Hospital Charge Code |
63000352
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$298.88 |
| Max. Negotiated Rate |
$370.61 |
| Rate for Payer: Aetna Commercial |
$344.30
|
| Rate for Payer: Cash Price |
$239.10
|
| Rate for Payer: Cigna All Commercial |
$343.91
|
| Rate for Payer: CORVEL All Commercial |
$370.61
|
| Rate for Payer: Coventry All Commercial |
$350.68
|
| Rate for Payer: Encore All Commercial |
$366.82
|
| Rate for Payer: Frontpath All Commercial |
$366.62
|
| Rate for Payer: Humana ChoiceCare |
$344.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$358.65
|
| Rate for Payer: PHCS All Commercial |
$298.88
|
| Rate for Payer: PHP All Commercial |
$302.22
|
| Rate for Payer: Sagamore Health Network All Products |
$307.64
|
| Rate for Payer: Signature Care EPO |
$330.75
|
| Rate for Payer: Signature Care PPO |
$350.68
|
| Rate for Payer: United Healthcare Commercial |
$314.02
|
|
