|
HC X-RAY-TIBIA-FIBULA 2 VIEWS BI
|
Facility
|
IP
|
$623.13
|
|
|
Service Code
|
CPT 73590 50
|
| Hospital Charge Code |
21613590
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$467.35 |
| Max. Negotiated Rate |
$579.51 |
| Rate for Payer: Aetna Commercial |
$538.38
|
| Rate for Payer: Cash Price |
$373.88
|
| Rate for Payer: Cigna All Commercial |
$537.76
|
| Rate for Payer: CORVEL All Commercial |
$579.51
|
| Rate for Payer: Coventry All Commercial |
$548.35
|
| Rate for Payer: Encore All Commercial |
$573.59
|
| Rate for Payer: Frontpath All Commercial |
$573.28
|
| Rate for Payer: Humana ChoiceCare |
$538.20
|
| Rate for Payer: Lutheran Preferred All Commercial |
$560.82
|
| Rate for Payer: PHCS All Commercial |
$467.35
|
| Rate for Payer: PHP All Commercial |
$472.58
|
| Rate for Payer: Sagamore Health Network All Products |
$481.06
|
| Rate for Payer: Signature Care EPO |
$517.20
|
| Rate for Payer: Signature Care PPO |
$548.35
|
| Rate for Payer: United Healthcare Commercial |
$491.03
|
|
|
HC X-RAY-TIBIA-FIBULA 2 VIEWS LT
|
Facility
|
OP
|
$415.42
|
|
|
Service Code
|
CPT 73590 LT
|
| Hospital Charge Code |
1613590
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$13.29 |
| Max. Negotiated Rate |
$386.34 |
| Rate for Payer: Aetna Commercial |
$350.61
|
| Rate for Payer: Aetna Medicare |
$132.93
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$13.29
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$128.78
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$238.58
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$259.68
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$13.29
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$152.87
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$146.23
|
| Rate for Payer: Cash Price |
$249.25
|
| Rate for Payer: Cash Price |
$249.25
|
| Rate for Payer: Centivo All Commercial |
$225.99
|
| Rate for Payer: Cigna All Commercial |
$358.51
|
| Rate for Payer: CORVEL All Commercial |
$386.34
|
| Rate for Payer: Coventry All Commercial |
$365.57
|
| Rate for Payer: Encore All Commercial |
$382.39
|
| Rate for Payer: Frontpath All Commercial |
$382.19
|
| Rate for Payer: Humana ChoiceCare |
$358.80
|
| Rate for Payer: Humana Medicare |
$132.93
|
| Rate for Payer: Lucent All Commercial |
$225.99
|
| Rate for Payer: Lutheran Preferred All Commercial |
$373.88
|
| Rate for Payer: Managed Health Services Medicaid |
$13.29
|
| Rate for Payer: MDWise Medicaid |
$13.29
|
| Rate for Payer: PHCS All Commercial |
$311.56
|
| Rate for Payer: PHP All Commercial |
$315.05
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$162.01
|
| Rate for Payer: Sagamore Health Network All Products |
$320.70
|
| Rate for Payer: Signature Care EPO |
$344.80
|
| Rate for Payer: Signature Care PPO |
$365.57
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$353.11
|
| Rate for Payer: United Healthcare Commercial |
$327.35
|
| Rate for Payer: United Healthcare Medicare |
$132.93
|
|
|
HC X-RAY-TIBIA-FIBULA 2 VIEWS LT
|
Facility
|
IP
|
$415.42
|
|
|
Service Code
|
CPT 73590 LT
|
| Hospital Charge Code |
1613590
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$311.56 |
| Max. Negotiated Rate |
$386.34 |
| Rate for Payer: Aetna Commercial |
$358.92
|
| Rate for Payer: Cash Price |
$249.25
|
| Rate for Payer: Cigna All Commercial |
$358.51
|
| Rate for Payer: CORVEL All Commercial |
$386.34
|
| Rate for Payer: Coventry All Commercial |
$365.57
|
| Rate for Payer: Encore All Commercial |
$382.39
|
| Rate for Payer: Frontpath All Commercial |
$382.19
|
| Rate for Payer: Humana ChoiceCare |
$358.80
|
| Rate for Payer: Lutheran Preferred All Commercial |
$373.88
|
| Rate for Payer: PHCS All Commercial |
$311.56
|
| Rate for Payer: PHP All Commercial |
$315.05
|
| Rate for Payer: Sagamore Health Network All Products |
$320.70
|
| Rate for Payer: Signature Care EPO |
$344.80
|
| Rate for Payer: Signature Care PPO |
$365.57
|
| Rate for Payer: United Healthcare Commercial |
$327.35
|
|
|
HC X-RAY-TIBIA-FIBULA 2 VIEWS RT
|
Facility
|
IP
|
$415.42
|
|
|
Service Code
|
CPT 73590 RT
|
| Hospital Charge Code |
11613590
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$311.56 |
| Max. Negotiated Rate |
$386.34 |
| Rate for Payer: Aetna Commercial |
$358.92
|
| Rate for Payer: Cash Price |
$249.25
|
| Rate for Payer: Cigna All Commercial |
$358.51
|
| Rate for Payer: CORVEL All Commercial |
$386.34
|
| Rate for Payer: Coventry All Commercial |
$365.57
|
| Rate for Payer: Encore All Commercial |
$382.39
|
| Rate for Payer: Frontpath All Commercial |
$382.19
|
| Rate for Payer: Humana ChoiceCare |
$358.80
|
| Rate for Payer: Lutheran Preferred All Commercial |
$373.88
|
| Rate for Payer: PHCS All Commercial |
$311.56
|
| Rate for Payer: PHP All Commercial |
$315.05
|
| Rate for Payer: Sagamore Health Network All Products |
$320.70
|
| Rate for Payer: Signature Care EPO |
$344.80
|
| Rate for Payer: Signature Care PPO |
$365.57
|
| Rate for Payer: United Healthcare Commercial |
$327.35
|
|
|
HC X-RAY-TIBIA-FIBULA 2 VIEWS RT
|
Facility
|
OP
|
$415.42
|
|
|
Service Code
|
CPT 73590 RT
|
| Hospital Charge Code |
11613590
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$13.29 |
| Max. Negotiated Rate |
$386.34 |
| Rate for Payer: Aetna Commercial |
$350.61
|
| Rate for Payer: Aetna Medicare |
$132.93
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$13.29
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$128.78
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$238.58
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$259.68
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$13.29
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$152.87
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$146.23
|
| Rate for Payer: Cash Price |
$249.25
|
| Rate for Payer: Cash Price |
$249.25
|
| Rate for Payer: Centivo All Commercial |
$225.99
|
| Rate for Payer: Cigna All Commercial |
$358.51
|
| Rate for Payer: CORVEL All Commercial |
$386.34
|
| Rate for Payer: Coventry All Commercial |
$365.57
|
| Rate for Payer: Encore All Commercial |
$382.39
|
| Rate for Payer: Frontpath All Commercial |
$382.19
|
| Rate for Payer: Humana ChoiceCare |
$358.80
|
| Rate for Payer: Humana Medicare |
$132.93
|
| Rate for Payer: Lucent All Commercial |
$225.99
|
| Rate for Payer: Lutheran Preferred All Commercial |
$373.88
|
| Rate for Payer: Managed Health Services Medicaid |
$13.29
|
| Rate for Payer: MDWise Medicaid |
$13.29
|
| Rate for Payer: PHCS All Commercial |
$311.56
|
| Rate for Payer: PHP All Commercial |
$315.05
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$162.01
|
| Rate for Payer: Sagamore Health Network All Products |
$320.70
|
| Rate for Payer: Signature Care EPO |
$344.80
|
| Rate for Payer: Signature Care PPO |
$365.57
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$353.11
|
| Rate for Payer: United Healthcare Commercial |
$327.35
|
| Rate for Payer: United Healthcare Medicare |
$132.93
|
|
|
HC X-RAY TMJ JOINT - LT
|
Facility
|
IP
|
$398.74
|
|
|
Service Code
|
CPT 70328 LT
|
| Hospital Charge Code |
1611328
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$299.06 |
| Max. Negotiated Rate |
$370.83 |
| Rate for Payer: Aetna Commercial |
$344.51
|
| Rate for Payer: Cash Price |
$239.24
|
| Rate for Payer: Cigna All Commercial |
$344.11
|
| Rate for Payer: CORVEL All Commercial |
$370.83
|
| Rate for Payer: Coventry All Commercial |
$350.89
|
| Rate for Payer: Encore All Commercial |
$367.04
|
| Rate for Payer: Frontpath All Commercial |
$366.84
|
| Rate for Payer: Humana ChoiceCare |
$344.39
|
| Rate for Payer: Lutheran Preferred All Commercial |
$358.87
|
| Rate for Payer: PHCS All Commercial |
$299.06
|
| Rate for Payer: PHP All Commercial |
$302.40
|
| Rate for Payer: Sagamore Health Network All Products |
$307.83
|
| Rate for Payer: Signature Care EPO |
$330.95
|
| Rate for Payer: Signature Care PPO |
$350.89
|
| Rate for Payer: United Healthcare Commercial |
$314.21
|
|
|
HC X-RAY TMJ JOINT - LT
|
Facility
|
OP
|
$398.74
|
|
|
Service Code
|
CPT 70328 LT
|
| Hospital Charge Code |
1611328
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$15.77 |
| Max. Negotiated Rate |
$370.83 |
| Rate for Payer: Aetna Commercial |
$336.54
|
| Rate for Payer: Aetna Medicare |
$127.60
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$15.77
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$123.61
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$229.00
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$249.25
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$15.77
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$146.74
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$140.36
|
| Rate for Payer: Cash Price |
$239.24
|
| Rate for Payer: Cash Price |
$239.24
|
| Rate for Payer: Centivo All Commercial |
$216.91
|
| Rate for Payer: Cigna All Commercial |
$344.11
|
| Rate for Payer: CORVEL All Commercial |
$370.83
|
| Rate for Payer: Coventry All Commercial |
$350.89
|
| Rate for Payer: Encore All Commercial |
$367.04
|
| Rate for Payer: Frontpath All Commercial |
$366.84
|
| Rate for Payer: Humana ChoiceCare |
$344.39
|
| Rate for Payer: Humana Medicare |
$127.60
|
| Rate for Payer: Lucent All Commercial |
$216.91
|
| Rate for Payer: Lutheran Preferred All Commercial |
$358.87
|
| Rate for Payer: Managed Health Services Medicaid |
$15.77
|
| Rate for Payer: MDWise Medicaid |
$15.77
|
| Rate for Payer: PHCS All Commercial |
$299.06
|
| Rate for Payer: PHP All Commercial |
$302.40
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$155.51
|
| Rate for Payer: Sagamore Health Network All Products |
$307.83
|
| Rate for Payer: Signature Care EPO |
$330.95
|
| Rate for Payer: Signature Care PPO |
$350.89
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$338.93
|
| Rate for Payer: United Healthcare Commercial |
$314.21
|
| Rate for Payer: United Healthcare Medicare |
$127.60
|
|
|
HC X-RAY TMJ JOINT - RT
|
Facility
|
IP
|
$398.74
|
|
|
Service Code
|
CPT 70328 RT
|
| Hospital Charge Code |
11611328
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$299.06 |
| Max. Negotiated Rate |
$370.83 |
| Rate for Payer: Aetna Commercial |
$344.51
|
| Rate for Payer: Cash Price |
$239.24
|
| Rate for Payer: Cigna All Commercial |
$344.11
|
| Rate for Payer: CORVEL All Commercial |
$370.83
|
| Rate for Payer: Coventry All Commercial |
$350.89
|
| Rate for Payer: Encore All Commercial |
$367.04
|
| Rate for Payer: Frontpath All Commercial |
$366.84
|
| Rate for Payer: Humana ChoiceCare |
$344.39
|
| Rate for Payer: Lutheran Preferred All Commercial |
$358.87
|
| Rate for Payer: PHCS All Commercial |
$299.06
|
| Rate for Payer: PHP All Commercial |
$302.40
|
| Rate for Payer: Sagamore Health Network All Products |
$307.83
|
| Rate for Payer: Signature Care EPO |
$330.95
|
| Rate for Payer: Signature Care PPO |
$350.89
|
| Rate for Payer: United Healthcare Commercial |
$314.21
|
|
|
HC X-RAY TMJ JOINT - RT
|
Facility
|
OP
|
$398.74
|
|
|
Service Code
|
CPT 70328 RT
|
| Hospital Charge Code |
11611328
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$15.77 |
| Max. Negotiated Rate |
$370.83 |
| Rate for Payer: Aetna Commercial |
$336.54
|
| Rate for Payer: Aetna Medicare |
$127.60
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$15.77
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$123.61
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$229.00
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$249.25
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$15.77
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$146.74
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$140.36
|
| Rate for Payer: Cash Price |
$239.24
|
| Rate for Payer: Cash Price |
$239.24
|
| Rate for Payer: Centivo All Commercial |
$216.91
|
| Rate for Payer: Cigna All Commercial |
$344.11
|
| Rate for Payer: CORVEL All Commercial |
$370.83
|
| Rate for Payer: Coventry All Commercial |
$350.89
|
| Rate for Payer: Encore All Commercial |
$367.04
|
| Rate for Payer: Frontpath All Commercial |
$366.84
|
| Rate for Payer: Humana ChoiceCare |
$344.39
|
| Rate for Payer: Humana Medicare |
$127.60
|
| Rate for Payer: Lucent All Commercial |
$216.91
|
| Rate for Payer: Lutheran Preferred All Commercial |
$358.87
|
| Rate for Payer: Managed Health Services Medicaid |
$15.77
|
| Rate for Payer: MDWise Medicaid |
$15.77
|
| Rate for Payer: PHCS All Commercial |
$299.06
|
| Rate for Payer: PHP All Commercial |
$302.40
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$155.51
|
| Rate for Payer: Sagamore Health Network All Products |
$307.83
|
| Rate for Payer: Signature Care EPO |
$330.95
|
| Rate for Payer: Signature Care PPO |
$350.89
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$338.93
|
| Rate for Payer: United Healthcare Commercial |
$314.21
|
| Rate for Payer: United Healthcare Medicare |
$127.60
|
|
|
HC X-RAY-TOE 2+ VIEWS BI
|
Facility
|
IP
|
$568.14
|
|
|
Service Code
|
CPT 73660 50
|
| Hospital Charge Code |
21613660
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$426.11 |
| Max. Negotiated Rate |
$528.37 |
| Rate for Payer: Aetna Commercial |
$490.87
|
| Rate for Payer: Cash Price |
$340.88
|
| Rate for Payer: Cigna All Commercial |
$490.30
|
| Rate for Payer: CORVEL All Commercial |
$528.37
|
| Rate for Payer: Coventry All Commercial |
$499.96
|
| Rate for Payer: Encore All Commercial |
$522.97
|
| Rate for Payer: Frontpath All Commercial |
$522.69
|
| Rate for Payer: Humana ChoiceCare |
$490.70
|
| Rate for Payer: Lutheran Preferred All Commercial |
$511.33
|
| Rate for Payer: PHCS All Commercial |
$426.11
|
| Rate for Payer: PHP All Commercial |
$430.88
|
| Rate for Payer: Sagamore Health Network All Products |
$438.60
|
| Rate for Payer: Signature Care EPO |
$471.56
|
| Rate for Payer: Signature Care PPO |
$499.96
|
| Rate for Payer: United Healthcare Commercial |
$447.69
|
|
|
HC X-RAY-TOE 2+ VIEWS BI
|
Facility
|
OP
|
$568.14
|
|
|
Service Code
|
CPT 73660 50
|
| Hospital Charge Code |
21613660
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$16.76 |
| Max. Negotiated Rate |
$528.37 |
| Rate for Payer: Aetna Commercial |
$479.51
|
| Rate for Payer: Aetna Medicare |
$181.80
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$16.76
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$176.12
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$326.28
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$355.14
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$16.76
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$209.08
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$199.99
|
| Rate for Payer: Cash Price |
$340.88
|
| Rate for Payer: Cash Price |
$340.88
|
| Rate for Payer: Centivo All Commercial |
$309.07
|
| Rate for Payer: Cigna All Commercial |
$490.30
|
| Rate for Payer: CORVEL All Commercial |
$528.37
|
| Rate for Payer: Coventry All Commercial |
$499.96
|
| Rate for Payer: Encore All Commercial |
$522.97
|
| Rate for Payer: Frontpath All Commercial |
$522.69
|
| Rate for Payer: Humana ChoiceCare |
$490.70
|
| Rate for Payer: Humana Medicare |
$181.80
|
| Rate for Payer: Lucent All Commercial |
$309.07
|
| Rate for Payer: Lutheran Preferred All Commercial |
$511.33
|
| Rate for Payer: Managed Health Services Medicaid |
$16.76
|
| Rate for Payer: MDWise Medicaid |
$16.76
|
| Rate for Payer: PHCS All Commercial |
$426.11
|
| Rate for Payer: PHP All Commercial |
$430.88
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$221.57
|
| Rate for Payer: Sagamore Health Network All Products |
$438.60
|
| Rate for Payer: Signature Care EPO |
$471.56
|
| Rate for Payer: Signature Care PPO |
$499.96
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$482.92
|
| Rate for Payer: United Healthcare Commercial |
$447.69
|
| Rate for Payer: United Healthcare Medicare |
$181.80
|
|
|
HC X-RAY-TOE 2+ VIEWS LT
|
Facility
|
IP
|
$284.07
|
|
|
Service Code
|
CPT 73660 LT
|
| Hospital Charge Code |
1613660
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$213.05 |
| Max. Negotiated Rate |
$264.19 |
| Rate for Payer: Aetna Commercial |
$245.44
|
| Rate for Payer: Cash Price |
$170.44
|
| Rate for Payer: Cigna All Commercial |
$245.15
|
| Rate for Payer: CORVEL All Commercial |
$264.19
|
| Rate for Payer: Coventry All Commercial |
$249.98
|
| Rate for Payer: Encore All Commercial |
$261.49
|
| Rate for Payer: Frontpath All Commercial |
$261.34
|
| Rate for Payer: Humana ChoiceCare |
$245.35
|
| Rate for Payer: Lutheran Preferred All Commercial |
$255.66
|
| Rate for Payer: PHCS All Commercial |
$213.05
|
| Rate for Payer: PHP All Commercial |
$215.44
|
| Rate for Payer: Sagamore Health Network All Products |
$219.30
|
| Rate for Payer: Signature Care EPO |
$235.78
|
| Rate for Payer: Signature Care PPO |
$249.98
|
| Rate for Payer: United Healthcare Commercial |
$223.85
|
|
|
HC X-RAY-TOE 2+ VIEWS LT
|
Facility
|
OP
|
$284.07
|
|
|
Service Code
|
CPT 73660 LT
|
| Hospital Charge Code |
1613660
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$16.76 |
| Max. Negotiated Rate |
$264.19 |
| Rate for Payer: Aetna Commercial |
$239.76
|
| Rate for Payer: Aetna Medicare |
$90.90
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$16.76
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$88.06
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$163.14
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$177.57
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$16.76
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$104.54
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$99.99
|
| Rate for Payer: Cash Price |
$170.44
|
| Rate for Payer: Cash Price |
$170.44
|
| Rate for Payer: Centivo All Commercial |
$154.53
|
| Rate for Payer: Cigna All Commercial |
$245.15
|
| Rate for Payer: CORVEL All Commercial |
$264.19
|
| Rate for Payer: Coventry All Commercial |
$249.98
|
| Rate for Payer: Encore All Commercial |
$261.49
|
| Rate for Payer: Frontpath All Commercial |
$261.34
|
| Rate for Payer: Humana ChoiceCare |
$245.35
|
| Rate for Payer: Humana Medicare |
$90.90
|
| Rate for Payer: Lucent All Commercial |
$154.53
|
| Rate for Payer: Lutheran Preferred All Commercial |
$255.66
|
| Rate for Payer: Managed Health Services Medicaid |
$16.76
|
| Rate for Payer: MDWise Medicaid |
$16.76
|
| Rate for Payer: PHCS All Commercial |
$213.05
|
| Rate for Payer: PHP All Commercial |
$215.44
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$110.79
|
| Rate for Payer: Sagamore Health Network All Products |
$219.30
|
| Rate for Payer: Signature Care EPO |
$235.78
|
| Rate for Payer: Signature Care PPO |
$249.98
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$241.46
|
| Rate for Payer: United Healthcare Commercial |
$223.85
|
| Rate for Payer: United Healthcare Medicare |
$90.90
|
|
|
HC X-RAY-TOE 2+ VIEWS RT
|
Facility
|
OP
|
$284.07
|
|
|
Service Code
|
CPT 73660 RT
|
| Hospital Charge Code |
11613660
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$16.76 |
| Max. Negotiated Rate |
$264.19 |
| Rate for Payer: Aetna Commercial |
$239.76
|
| Rate for Payer: Aetna Medicare |
$90.90
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$16.76
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$88.06
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$163.14
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$177.57
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$16.76
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$104.54
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$99.99
|
| Rate for Payer: Cash Price |
$170.44
|
| Rate for Payer: Cash Price |
$170.44
|
| Rate for Payer: Centivo All Commercial |
$154.53
|
| Rate for Payer: Cigna All Commercial |
$245.15
|
| Rate for Payer: CORVEL All Commercial |
$264.19
|
| Rate for Payer: Coventry All Commercial |
$249.98
|
| Rate for Payer: Encore All Commercial |
$261.49
|
| Rate for Payer: Frontpath All Commercial |
$261.34
|
| Rate for Payer: Humana ChoiceCare |
$245.35
|
| Rate for Payer: Humana Medicare |
$90.90
|
| Rate for Payer: Lucent All Commercial |
$154.53
|
| Rate for Payer: Lutheran Preferred All Commercial |
$255.66
|
| Rate for Payer: Managed Health Services Medicaid |
$16.76
|
| Rate for Payer: MDWise Medicaid |
$16.76
|
| Rate for Payer: PHCS All Commercial |
$213.05
|
| Rate for Payer: PHP All Commercial |
$215.44
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$110.79
|
| Rate for Payer: Sagamore Health Network All Products |
$219.30
|
| Rate for Payer: Signature Care EPO |
$235.78
|
| Rate for Payer: Signature Care PPO |
$249.98
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$241.46
|
| Rate for Payer: United Healthcare Commercial |
$223.85
|
| Rate for Payer: United Healthcare Medicare |
$90.90
|
|
|
HC X-RAY-TOE 2+ VIEWS RT
|
Facility
|
IP
|
$284.07
|
|
|
Service Code
|
CPT 73660 RT
|
| Hospital Charge Code |
11613660
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$213.05 |
| Max. Negotiated Rate |
$264.19 |
| Rate for Payer: Aetna Commercial |
$245.44
|
| Rate for Payer: Cash Price |
$170.44
|
| Rate for Payer: Cigna All Commercial |
$245.15
|
| Rate for Payer: CORVEL All Commercial |
$264.19
|
| Rate for Payer: Coventry All Commercial |
$249.98
|
| Rate for Payer: Encore All Commercial |
$261.49
|
| Rate for Payer: Frontpath All Commercial |
$261.34
|
| Rate for Payer: Humana ChoiceCare |
$245.35
|
| Rate for Payer: Lutheran Preferred All Commercial |
$255.66
|
| Rate for Payer: PHCS All Commercial |
$213.05
|
| Rate for Payer: PHP All Commercial |
$215.44
|
| Rate for Payer: Sagamore Health Network All Products |
$219.30
|
| Rate for Payer: Signature Care EPO |
$235.78
|
| Rate for Payer: Signature Care PPO |
$249.98
|
| Rate for Payer: United Healthcare Commercial |
$223.85
|
|
|
HC X-RAY-UPPER EXT AP&LAT INF BI
|
Facility
|
IP
|
$432.06
|
|
|
Service Code
|
CPT 73092 50
|
| Hospital Charge Code |
21613092
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$324.05 |
| Max. Negotiated Rate |
$401.82 |
| Rate for Payer: Aetna Commercial |
$373.30
|
| Rate for Payer: Cash Price |
$259.24
|
| Rate for Payer: Cigna All Commercial |
$372.87
|
| Rate for Payer: CORVEL All Commercial |
$401.82
|
| Rate for Payer: Coventry All Commercial |
$380.21
|
| Rate for Payer: Encore All Commercial |
$397.71
|
| Rate for Payer: Frontpath All Commercial |
$397.50
|
| Rate for Payer: Humana ChoiceCare |
$373.17
|
| Rate for Payer: Lutheran Preferred All Commercial |
$388.85
|
| Rate for Payer: PHCS All Commercial |
$324.05
|
| Rate for Payer: PHP All Commercial |
$327.67
|
| Rate for Payer: Sagamore Health Network All Products |
$333.55
|
| Rate for Payer: Signature Care EPO |
$358.61
|
| Rate for Payer: Signature Care PPO |
$380.21
|
| Rate for Payer: United Healthcare Commercial |
$340.46
|
|
|
HC X-RAY-UPPER EXT AP&LAT INF BI
|
Facility
|
OP
|
$432.06
|
|
|
Service Code
|
CPT 73092 50
|
| Hospital Charge Code |
21613092
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$14.28 |
| Max. Negotiated Rate |
$401.82 |
| Rate for Payer: Aetna Commercial |
$364.66
|
| Rate for Payer: Aetna Medicare |
$138.26
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$14.28
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$133.94
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$248.13
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$270.08
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$14.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$159.00
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$152.09
|
| Rate for Payer: Cash Price |
$259.24
|
| Rate for Payer: Cash Price |
$259.24
|
| Rate for Payer: Centivo All Commercial |
$235.04
|
| Rate for Payer: Cigna All Commercial |
$372.87
|
| Rate for Payer: CORVEL All Commercial |
$401.82
|
| Rate for Payer: Coventry All Commercial |
$380.21
|
| Rate for Payer: Encore All Commercial |
$397.71
|
| Rate for Payer: Frontpath All Commercial |
$397.50
|
| Rate for Payer: Humana ChoiceCare |
$373.17
|
| Rate for Payer: Humana Medicare |
$138.26
|
| Rate for Payer: Lucent All Commercial |
$235.04
|
| Rate for Payer: Lutheran Preferred All Commercial |
$388.85
|
| Rate for Payer: Managed Health Services Medicaid |
$14.28
|
| Rate for Payer: MDWise Medicaid |
$14.28
|
| Rate for Payer: PHCS All Commercial |
$324.05
|
| Rate for Payer: PHP All Commercial |
$327.67
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$168.50
|
| Rate for Payer: Sagamore Health Network All Products |
$333.55
|
| Rate for Payer: Signature Care EPO |
$358.61
|
| Rate for Payer: Signature Care PPO |
$380.21
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$367.25
|
| Rate for Payer: United Healthcare Commercial |
$340.46
|
| Rate for Payer: United Healthcare Medicare |
$138.26
|
|
|
HC X-RAY-UPPER EXT AP&LAT INF LT
|
Facility
|
IP
|
$288.04
|
|
|
Service Code
|
CPT 73092 LT
|
| Hospital Charge Code |
1613092
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$216.03 |
| Max. Negotiated Rate |
$267.88 |
| Rate for Payer: Aetna Commercial |
$248.87
|
| Rate for Payer: Cash Price |
$172.82
|
| Rate for Payer: Cigna All Commercial |
$248.58
|
| Rate for Payer: CORVEL All Commercial |
$267.88
|
| Rate for Payer: Coventry All Commercial |
$253.48
|
| Rate for Payer: Encore All Commercial |
$265.14
|
| Rate for Payer: Frontpath All Commercial |
$265.00
|
| Rate for Payer: Humana ChoiceCare |
$248.78
|
| Rate for Payer: Lutheran Preferred All Commercial |
$259.24
|
| Rate for Payer: PHCS All Commercial |
$216.03
|
| Rate for Payer: PHP All Commercial |
$218.45
|
| Rate for Payer: Sagamore Health Network All Products |
$222.37
|
| Rate for Payer: Signature Care EPO |
$239.07
|
| Rate for Payer: Signature Care PPO |
$253.48
|
| Rate for Payer: United Healthcare Commercial |
$226.98
|
|
|
HC X-RAY-UPPER EXT AP&LAT INF LT
|
Facility
|
OP
|
$288.04
|
|
|
Service Code
|
CPT 73092 LT
|
| Hospital Charge Code |
1613092
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$14.28 |
| Max. Negotiated Rate |
$267.88 |
| Rate for Payer: Aetna Commercial |
$243.11
|
| Rate for Payer: Aetna Medicare |
$92.17
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$14.28
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$89.29
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$165.42
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$180.05
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$14.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$106.00
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$101.39
|
| Rate for Payer: Cash Price |
$172.82
|
| Rate for Payer: Cash Price |
$172.82
|
| Rate for Payer: Centivo All Commercial |
$156.69
|
| Rate for Payer: Cigna All Commercial |
$248.58
|
| Rate for Payer: CORVEL All Commercial |
$267.88
|
| Rate for Payer: Coventry All Commercial |
$253.48
|
| Rate for Payer: Encore All Commercial |
$265.14
|
| Rate for Payer: Frontpath All Commercial |
$265.00
|
| Rate for Payer: Humana ChoiceCare |
$248.78
|
| Rate for Payer: Humana Medicare |
$92.17
|
| Rate for Payer: Lucent All Commercial |
$156.69
|
| Rate for Payer: Lutheran Preferred All Commercial |
$259.24
|
| Rate for Payer: Managed Health Services Medicaid |
$14.28
|
| Rate for Payer: MDWise Medicaid |
$14.28
|
| Rate for Payer: PHCS All Commercial |
$216.03
|
| Rate for Payer: PHP All Commercial |
$218.45
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$112.34
|
| Rate for Payer: Sagamore Health Network All Products |
$222.37
|
| Rate for Payer: Signature Care EPO |
$239.07
|
| Rate for Payer: Signature Care PPO |
$253.48
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$244.83
|
| Rate for Payer: United Healthcare Commercial |
$226.98
|
| Rate for Payer: United Healthcare Medicare |
$92.17
|
|
|
HC X-RAY-UPPER EXT AP&LAT INF RT
|
Facility
|
IP
|
$288.04
|
|
|
Service Code
|
CPT 73092 RT
|
| Hospital Charge Code |
11613092
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$216.03 |
| Max. Negotiated Rate |
$267.88 |
| Rate for Payer: Aetna Commercial |
$248.87
|
| Rate for Payer: Cash Price |
$172.82
|
| Rate for Payer: Cigna All Commercial |
$248.58
|
| Rate for Payer: CORVEL All Commercial |
$267.88
|
| Rate for Payer: Coventry All Commercial |
$253.48
|
| Rate for Payer: Encore All Commercial |
$265.14
|
| Rate for Payer: Frontpath All Commercial |
$265.00
|
| Rate for Payer: Humana ChoiceCare |
$248.78
|
| Rate for Payer: Lutheran Preferred All Commercial |
$259.24
|
| Rate for Payer: PHCS All Commercial |
$216.03
|
| Rate for Payer: PHP All Commercial |
$218.45
|
| Rate for Payer: Sagamore Health Network All Products |
$222.37
|
| Rate for Payer: Signature Care EPO |
$239.07
|
| Rate for Payer: Signature Care PPO |
$253.48
|
| Rate for Payer: United Healthcare Commercial |
$226.98
|
|
|
HC X-RAY-UPPER EXT AP&LAT INF RT
|
Facility
|
OP
|
$288.04
|
|
|
Service Code
|
CPT 73092 RT
|
| Hospital Charge Code |
11613092
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$14.28 |
| Max. Negotiated Rate |
$267.88 |
| Rate for Payer: Aetna Commercial |
$243.11
|
| Rate for Payer: Aetna Medicare |
$92.17
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$14.28
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$89.29
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$165.42
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$180.05
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$14.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$106.00
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$101.39
|
| Rate for Payer: Cash Price |
$172.82
|
| Rate for Payer: Cash Price |
$172.82
|
| Rate for Payer: Centivo All Commercial |
$156.69
|
| Rate for Payer: Cigna All Commercial |
$248.58
|
| Rate for Payer: CORVEL All Commercial |
$267.88
|
| Rate for Payer: Coventry All Commercial |
$253.48
|
| Rate for Payer: Encore All Commercial |
$265.14
|
| Rate for Payer: Frontpath All Commercial |
$265.00
|
| Rate for Payer: Humana ChoiceCare |
$248.78
|
| Rate for Payer: Humana Medicare |
$92.17
|
| Rate for Payer: Lucent All Commercial |
$156.69
|
| Rate for Payer: Lutheran Preferred All Commercial |
$259.24
|
| Rate for Payer: Managed Health Services Medicaid |
$14.28
|
| Rate for Payer: MDWise Medicaid |
$14.28
|
| Rate for Payer: PHCS All Commercial |
$216.03
|
| Rate for Payer: PHP All Commercial |
$218.45
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$112.34
|
| Rate for Payer: Sagamore Health Network All Products |
$222.37
|
| Rate for Payer: Signature Care EPO |
$239.07
|
| Rate for Payer: Signature Care PPO |
$253.48
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$244.83
|
| Rate for Payer: United Healthcare Commercial |
$226.98
|
| Rate for Payer: United Healthcare Medicare |
$92.17
|
|
|
HC X-RAY UPPER GI DOUBLE CONTRAST W/O KUB
|
Facility
|
OP
|
$1,372.01
|
|
|
Service Code
|
CPT 74246
|
| Hospital Charge Code |
1614241
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$67.05 |
| Max. Negotiated Rate |
$1,275.97 |
| Rate for Payer: Aetna Commercial |
$1,157.98
|
| Rate for Payer: Aetna Medicare |
$439.04
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$67.05
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$425.32
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$787.95
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$857.64
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$67.05
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$504.90
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$482.95
|
| Rate for Payer: Cash Price |
$823.21
|
| Rate for Payer: Cash Price |
$823.21
|
| Rate for Payer: Centivo All Commercial |
$746.37
|
| Rate for Payer: Cigna All Commercial |
$1,184.04
|
| Rate for Payer: CORVEL All Commercial |
$1,275.97
|
| Rate for Payer: Coventry All Commercial |
$1,207.37
|
| Rate for Payer: Encore All Commercial |
$1,262.94
|
| Rate for Payer: Frontpath All Commercial |
$1,262.25
|
| Rate for Payer: Humana ChoiceCare |
$1,185.01
|
| Rate for Payer: Humana Medicare |
$439.04
|
| Rate for Payer: Lucent All Commercial |
$746.37
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,234.81
|
| Rate for Payer: Managed Health Services Medicaid |
$67.05
|
| Rate for Payer: MDWise Medicaid |
$67.05
|
| Rate for Payer: PHCS All Commercial |
$1,029.01
|
| Rate for Payer: PHP All Commercial |
$1,040.53
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$535.08
|
| Rate for Payer: Sagamore Health Network All Products |
$1,059.19
|
| Rate for Payer: Signature Care EPO |
$1,138.77
|
| Rate for Payer: Signature Care PPO |
$1,207.37
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,166.21
|
| Rate for Payer: United Healthcare Commercial |
$1,081.14
|
| Rate for Payer: United Healthcare Medicare |
$439.04
|
|
|
HC X-RAY UPPER GI DOUBLE CONTRAST W/O KUB
|
Facility
|
IP
|
$1,372.01
|
|
|
Service Code
|
CPT 74246
|
| Hospital Charge Code |
1614241
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1,029.01 |
| Max. Negotiated Rate |
$1,275.97 |
| Rate for Payer: Aetna Commercial |
$1,185.42
|
| Rate for Payer: Cash Price |
$823.21
|
| Rate for Payer: Cigna All Commercial |
$1,184.04
|
| Rate for Payer: CORVEL All Commercial |
$1,275.97
|
| Rate for Payer: Coventry All Commercial |
$1,207.37
|
| Rate for Payer: Encore All Commercial |
$1,262.94
|
| Rate for Payer: Frontpath All Commercial |
$1,262.25
|
| Rate for Payer: Humana ChoiceCare |
$1,185.01
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,234.81
|
| Rate for Payer: PHCS All Commercial |
$1,029.01
|
| Rate for Payer: PHP All Commercial |
$1,040.53
|
| Rate for Payer: Sagamore Health Network All Products |
$1,059.19
|
| Rate for Payer: Signature Care EPO |
$1,138.77
|
| Rate for Payer: Signature Care PPO |
$1,207.37
|
| Rate for Payer: United Healthcare Commercial |
$1,081.14
|
|
|
HC X-RAY UPPER GI SINGLE CONTRAST W/O KUB
|
Facility
|
IP
|
$907.97
|
|
|
Service Code
|
CPT 74240
|
| Hospital Charge Code |
1614240
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$680.98 |
| Max. Negotiated Rate |
$844.41 |
| Rate for Payer: Aetna Commercial |
$784.49
|
| Rate for Payer: Cash Price |
$544.78
|
| Rate for Payer: Cigna All Commercial |
$783.58
|
| Rate for Payer: CORVEL All Commercial |
$844.41
|
| Rate for Payer: Coventry All Commercial |
$799.01
|
| Rate for Payer: Encore All Commercial |
$835.79
|
| Rate for Payer: Frontpath All Commercial |
$835.33
|
| Rate for Payer: Humana ChoiceCare |
$784.21
|
| Rate for Payer: Lutheran Preferred All Commercial |
$817.17
|
| Rate for Payer: PHCS All Commercial |
$680.98
|
| Rate for Payer: PHP All Commercial |
$688.60
|
| Rate for Payer: Sagamore Health Network All Products |
$700.95
|
| Rate for Payer: Signature Care EPO |
$753.62
|
| Rate for Payer: Signature Care PPO |
$799.01
|
| Rate for Payer: United Healthcare Commercial |
$715.48
|
|
|
HC X-RAY UPPER GI SINGLE CONTRAST W/O KUB
|
Facility
|
OP
|
$907.97
|
|
|
Service Code
|
CPT 74240
|
| Hospital Charge Code |
1614240
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$56.64 |
| Max. Negotiated Rate |
$844.41 |
| Rate for Payer: Aetna Commercial |
$766.33
|
| Rate for Payer: Aetna Medicare |
$290.55
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$56.64
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$281.47
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$521.45
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$567.57
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$56.64
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$334.13
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$319.61
|
| Rate for Payer: Cash Price |
$544.78
|
| Rate for Payer: Cash Price |
$544.78
|
| Rate for Payer: Centivo All Commercial |
$493.94
|
| Rate for Payer: Cigna All Commercial |
$783.58
|
| Rate for Payer: CORVEL All Commercial |
$844.41
|
| Rate for Payer: Coventry All Commercial |
$799.01
|
| Rate for Payer: Encore All Commercial |
$835.79
|
| Rate for Payer: Frontpath All Commercial |
$835.33
|
| Rate for Payer: Humana ChoiceCare |
$784.21
|
| Rate for Payer: Humana Medicare |
$290.55
|
| Rate for Payer: Lucent All Commercial |
$493.94
|
| Rate for Payer: Lutheran Preferred All Commercial |
$817.17
|
| Rate for Payer: Managed Health Services Medicaid |
$56.64
|
| Rate for Payer: MDWise Medicaid |
$56.64
|
| Rate for Payer: PHCS All Commercial |
$680.98
|
| Rate for Payer: PHP All Commercial |
$688.60
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$354.11
|
| Rate for Payer: Sagamore Health Network All Products |
$700.95
|
| Rate for Payer: Signature Care EPO |
$753.62
|
| Rate for Payer: Signature Care PPO |
$799.01
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$771.77
|
| Rate for Payer: United Healthcare Commercial |
$715.48
|
| Rate for Payer: United Healthcare Medicare |
$290.55
|
|
