|
HC X-RAY-VENOGRAM LT LOWER UNILAT
|
Facility
|
IP
|
$112.70
|
|
|
Service Code
|
CPT 75820 LT
|
| Hospital Charge Code |
1615820
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$84.53 |
| Max. Negotiated Rate |
$104.81 |
| Rate for Payer: Aetna Commercial |
$97.37
|
| Rate for Payer: Cash Price |
$67.62
|
| Rate for Payer: Cigna All Commercial |
$97.26
|
| Rate for Payer: CORVEL All Commercial |
$104.81
|
| Rate for Payer: Coventry All Commercial |
$99.18
|
| Rate for Payer: Encore All Commercial |
$103.74
|
| Rate for Payer: Frontpath All Commercial |
$103.68
|
| Rate for Payer: Humana ChoiceCare |
$97.34
|
| Rate for Payer: Lutheran Preferred All Commercial |
$101.43
|
| Rate for Payer: PHCS All Commercial |
$84.53
|
| Rate for Payer: PHP All Commercial |
$85.47
|
| Rate for Payer: Sagamore Health Network All Products |
$87.00
|
| Rate for Payer: Signature Care EPO |
$93.54
|
| Rate for Payer: Signature Care PPO |
$99.18
|
| Rate for Payer: United Healthcare Commercial |
$88.81
|
|
|
HC X-RAY-VENOGRAM LT LOWER UNILAT
|
Facility
|
OP
|
$112.70
|
|
|
Service Code
|
CPT 75820 LT
|
| Hospital Charge Code |
1615820
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$34.94 |
| Max. Negotiated Rate |
$104.81 |
| Rate for Payer: Aetna Commercial |
$95.12
|
| Rate for Payer: Aetna Medicare |
$36.06
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$62.84
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$34.94
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$64.72
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$70.45
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$62.84
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$41.47
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$39.67
|
| Rate for Payer: Cash Price |
$67.62
|
| Rate for Payer: Cash Price |
$67.62
|
| Rate for Payer: Centivo All Commercial |
$61.31
|
| Rate for Payer: Cigna All Commercial |
$97.26
|
| Rate for Payer: CORVEL All Commercial |
$104.81
|
| Rate for Payer: Coventry All Commercial |
$99.18
|
| Rate for Payer: Encore All Commercial |
$103.74
|
| Rate for Payer: Frontpath All Commercial |
$103.68
|
| Rate for Payer: Humana ChoiceCare |
$97.34
|
| Rate for Payer: Humana Medicare |
$36.06
|
| Rate for Payer: Lucent All Commercial |
$61.31
|
| Rate for Payer: Lutheran Preferred All Commercial |
$101.43
|
| Rate for Payer: Managed Health Services Medicaid |
$62.84
|
| Rate for Payer: MDWise Medicaid |
$62.84
|
| Rate for Payer: PHCS All Commercial |
$84.53
|
| Rate for Payer: PHP All Commercial |
$85.47
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$43.95
|
| Rate for Payer: Sagamore Health Network All Products |
$87.00
|
| Rate for Payer: Signature Care EPO |
$93.54
|
| Rate for Payer: Signature Care PPO |
$99.18
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$95.80
|
| Rate for Payer: United Healthcare Commercial |
$88.81
|
| Rate for Payer: United Healthcare Medicare |
$36.06
|
|
|
HC X-RAY-VENOGRAM LT UPPER UNILAT
|
Facility
|
OP
|
$112.70
|
|
|
Service Code
|
CPT 75820 LT
|
| Hospital Charge Code |
1615821
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$34.94 |
| Max. Negotiated Rate |
$104.81 |
| Rate for Payer: Aetna Commercial |
$95.12
|
| Rate for Payer: Aetna Medicare |
$36.06
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$62.84
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$34.94
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$64.72
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$70.45
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$62.84
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$41.47
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$39.67
|
| Rate for Payer: Cash Price |
$67.62
|
| Rate for Payer: Cash Price |
$67.62
|
| Rate for Payer: Centivo All Commercial |
$61.31
|
| Rate for Payer: Cigna All Commercial |
$97.26
|
| Rate for Payer: CORVEL All Commercial |
$104.81
|
| Rate for Payer: Coventry All Commercial |
$99.18
|
| Rate for Payer: Encore All Commercial |
$103.74
|
| Rate for Payer: Frontpath All Commercial |
$103.68
|
| Rate for Payer: Humana ChoiceCare |
$97.34
|
| Rate for Payer: Humana Medicare |
$36.06
|
| Rate for Payer: Lucent All Commercial |
$61.31
|
| Rate for Payer: Lutheran Preferred All Commercial |
$101.43
|
| Rate for Payer: Managed Health Services Medicaid |
$62.84
|
| Rate for Payer: MDWise Medicaid |
$62.84
|
| Rate for Payer: PHCS All Commercial |
$84.53
|
| Rate for Payer: PHP All Commercial |
$85.47
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$43.95
|
| Rate for Payer: Sagamore Health Network All Products |
$87.00
|
| Rate for Payer: Signature Care EPO |
$93.54
|
| Rate for Payer: Signature Care PPO |
$99.18
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$95.80
|
| Rate for Payer: United Healthcare Commercial |
$88.81
|
| Rate for Payer: United Healthcare Medicare |
$36.06
|
|
|
HC X-RAY-VENOGRAM LT UPPER UNILAT
|
Facility
|
IP
|
$112.70
|
|
|
Service Code
|
CPT 75820 LT
|
| Hospital Charge Code |
1615821
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$84.53 |
| Max. Negotiated Rate |
$104.81 |
| Rate for Payer: Aetna Commercial |
$97.37
|
| Rate for Payer: Cash Price |
$67.62
|
| Rate for Payer: Cigna All Commercial |
$97.26
|
| Rate for Payer: CORVEL All Commercial |
$104.81
|
| Rate for Payer: Coventry All Commercial |
$99.18
|
| Rate for Payer: Encore All Commercial |
$103.74
|
| Rate for Payer: Frontpath All Commercial |
$103.68
|
| Rate for Payer: Humana ChoiceCare |
$97.34
|
| Rate for Payer: Lutheran Preferred All Commercial |
$101.43
|
| Rate for Payer: PHCS All Commercial |
$84.53
|
| Rate for Payer: PHP All Commercial |
$85.47
|
| Rate for Payer: Sagamore Health Network All Products |
$87.00
|
| Rate for Payer: Signature Care EPO |
$93.54
|
| Rate for Payer: Signature Care PPO |
$99.18
|
| Rate for Payer: United Healthcare Commercial |
$88.81
|
|
|
HC X-RAY-VENOGRAM RT UPPER UNILAT
|
Facility
|
IP
|
$112.70
|
|
|
Service Code
|
CPT 75820 RT
|
| Hospital Charge Code |
11615821
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$84.53 |
| Max. Negotiated Rate |
$104.81 |
| Rate for Payer: Aetna Commercial |
$97.37
|
| Rate for Payer: Cash Price |
$67.62
|
| Rate for Payer: Cigna All Commercial |
$97.26
|
| Rate for Payer: CORVEL All Commercial |
$104.81
|
| Rate for Payer: Coventry All Commercial |
$99.18
|
| Rate for Payer: Encore All Commercial |
$103.74
|
| Rate for Payer: Frontpath All Commercial |
$103.68
|
| Rate for Payer: Humana ChoiceCare |
$97.34
|
| Rate for Payer: Lutheran Preferred All Commercial |
$101.43
|
| Rate for Payer: PHCS All Commercial |
$84.53
|
| Rate for Payer: PHP All Commercial |
$85.47
|
| Rate for Payer: Sagamore Health Network All Products |
$87.00
|
| Rate for Payer: Signature Care EPO |
$93.54
|
| Rate for Payer: Signature Care PPO |
$99.18
|
| Rate for Payer: United Healthcare Commercial |
$88.81
|
|
|
HC X-RAY-VENOGRAM RT UPPER UNILAT
|
Facility
|
OP
|
$112.70
|
|
|
Service Code
|
CPT 75820 RT
|
| Hospital Charge Code |
11615821
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$34.94 |
| Max. Negotiated Rate |
$104.81 |
| Rate for Payer: Aetna Commercial |
$95.12
|
| Rate for Payer: Aetna Medicare |
$36.06
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$62.84
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$34.94
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$64.72
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$70.45
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$62.84
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$41.47
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$39.67
|
| Rate for Payer: Cash Price |
$67.62
|
| Rate for Payer: Cash Price |
$67.62
|
| Rate for Payer: Centivo All Commercial |
$61.31
|
| Rate for Payer: Cigna All Commercial |
$97.26
|
| Rate for Payer: CORVEL All Commercial |
$104.81
|
| Rate for Payer: Coventry All Commercial |
$99.18
|
| Rate for Payer: Encore All Commercial |
$103.74
|
| Rate for Payer: Frontpath All Commercial |
$103.68
|
| Rate for Payer: Humana ChoiceCare |
$97.34
|
| Rate for Payer: Humana Medicare |
$36.06
|
| Rate for Payer: Lucent All Commercial |
$61.31
|
| Rate for Payer: Lutheran Preferred All Commercial |
$101.43
|
| Rate for Payer: Managed Health Services Medicaid |
$62.84
|
| Rate for Payer: MDWise Medicaid |
$62.84
|
| Rate for Payer: PHCS All Commercial |
$84.53
|
| Rate for Payer: PHP All Commercial |
$85.47
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$43.95
|
| Rate for Payer: Sagamore Health Network All Products |
$87.00
|
| Rate for Payer: Signature Care EPO |
$93.54
|
| Rate for Payer: Signature Care PPO |
$99.18
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$95.80
|
| Rate for Payer: United Healthcare Commercial |
$88.81
|
| Rate for Payer: United Healthcare Medicare |
$36.06
|
|
|
HC X-RAY-WRIST 1 VIEW BI
|
Facility
|
IP
|
$417.12
|
|
|
Service Code
|
CPT 73100 50,52
|
| Hospital Charge Code |
21615100
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$312.84 |
| Max. Negotiated Rate |
$387.92 |
| Rate for Payer: Aetna Commercial |
$360.39
|
| Rate for Payer: Cash Price |
$250.27
|
| Rate for Payer: Cigna All Commercial |
$359.97
|
| Rate for Payer: CORVEL All Commercial |
$387.92
|
| Rate for Payer: Coventry All Commercial |
$367.07
|
| Rate for Payer: Encore All Commercial |
$383.96
|
| Rate for Payer: Frontpath All Commercial |
$383.75
|
| Rate for Payer: Humana ChoiceCare |
$360.27
|
| Rate for Payer: Lutheran Preferred All Commercial |
$375.41
|
| Rate for Payer: PHCS All Commercial |
$312.84
|
| Rate for Payer: PHP All Commercial |
$316.34
|
| Rate for Payer: Sagamore Health Network All Products |
$322.02
|
| Rate for Payer: Signature Care EPO |
$346.21
|
| Rate for Payer: Signature Care PPO |
$367.07
|
| Rate for Payer: United Healthcare Commercial |
$328.69
|
|
|
HC X-RAY-WRIST 1 VIEW BI
|
Facility
|
OP
|
$417.12
|
|
|
Service Code
|
CPT 73100 50,52
|
| Hospital Charge Code |
21615100
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$15.77 |
| Max. Negotiated Rate |
$387.92 |
| Rate for Payer: Aetna Commercial |
$352.05
|
| Rate for Payer: Aetna Medicare |
$133.48
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$15.77
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$129.31
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$239.55
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$260.74
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$15.77
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$153.50
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$146.83
|
| Rate for Payer: Cash Price |
$250.27
|
| Rate for Payer: Cash Price |
$250.27
|
| Rate for Payer: Centivo All Commercial |
$226.91
|
| Rate for Payer: Cigna All Commercial |
$359.97
|
| Rate for Payer: CORVEL All Commercial |
$387.92
|
| Rate for Payer: Coventry All Commercial |
$367.07
|
| Rate for Payer: Encore All Commercial |
$383.96
|
| Rate for Payer: Frontpath All Commercial |
$383.75
|
| Rate for Payer: Humana ChoiceCare |
$360.27
|
| Rate for Payer: Humana Medicare |
$133.48
|
| Rate for Payer: Lucent All Commercial |
$226.91
|
| Rate for Payer: Lutheran Preferred All Commercial |
$375.41
|
| Rate for Payer: Managed Health Services Medicaid |
$15.77
|
| Rate for Payer: MDWise Medicaid |
$15.77
|
| Rate for Payer: PHCS All Commercial |
$312.84
|
| Rate for Payer: PHP All Commercial |
$316.34
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$162.68
|
| Rate for Payer: Sagamore Health Network All Products |
$322.02
|
| Rate for Payer: Signature Care EPO |
$346.21
|
| Rate for Payer: Signature Care PPO |
$367.07
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$354.55
|
| Rate for Payer: United Healthcare Commercial |
$328.69
|
| Rate for Payer: United Healthcare Medicare |
$133.48
|
|
|
HC X-RAY-WRIST 1 VIEW RT
|
Facility
|
OP
|
$278.08
|
|
|
Service Code
|
CPT 73100 RT,52
|
| Hospital Charge Code |
11615100
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$15.77 |
| Max. Negotiated Rate |
$258.61 |
| Rate for Payer: Aetna Commercial |
$234.70
|
| Rate for Payer: Aetna Medicare |
$88.99
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$15.77
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$86.20
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$159.70
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$173.83
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$15.77
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$102.33
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$97.88
|
| Rate for Payer: Cash Price |
$166.85
|
| Rate for Payer: Cash Price |
$166.85
|
| Rate for Payer: Centivo All Commercial |
$151.28
|
| Rate for Payer: Cigna All Commercial |
$239.98
|
| Rate for Payer: CORVEL All Commercial |
$258.61
|
| Rate for Payer: Coventry All Commercial |
$244.71
|
| Rate for Payer: Encore All Commercial |
$255.97
|
| Rate for Payer: Frontpath All Commercial |
$255.83
|
| Rate for Payer: Humana ChoiceCare |
$240.18
|
| Rate for Payer: Humana Medicare |
$88.99
|
| Rate for Payer: Lucent All Commercial |
$151.28
|
| Rate for Payer: Lutheran Preferred All Commercial |
$250.27
|
| Rate for Payer: Managed Health Services Medicaid |
$15.77
|
| Rate for Payer: MDWise Medicaid |
$15.77
|
| Rate for Payer: PHCS All Commercial |
$208.56
|
| Rate for Payer: PHP All Commercial |
$210.90
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$108.45
|
| Rate for Payer: Sagamore Health Network All Products |
$214.68
|
| Rate for Payer: Signature Care EPO |
$230.81
|
| Rate for Payer: Signature Care PPO |
$244.71
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$236.37
|
| Rate for Payer: United Healthcare Commercial |
$219.13
|
| Rate for Payer: United Healthcare Medicare |
$88.99
|
|
|
HC X-RAY-WRIST 1 VIEW RT
|
Facility
|
IP
|
$278.08
|
|
|
Service Code
|
CPT 73100 RT,52
|
| Hospital Charge Code |
11615100
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$208.56 |
| Max. Negotiated Rate |
$258.61 |
| Rate for Payer: Aetna Commercial |
$240.26
|
| Rate for Payer: Cash Price |
$166.85
|
| Rate for Payer: Cigna All Commercial |
$239.98
|
| Rate for Payer: CORVEL All Commercial |
$258.61
|
| Rate for Payer: Coventry All Commercial |
$244.71
|
| Rate for Payer: Encore All Commercial |
$255.97
|
| Rate for Payer: Frontpath All Commercial |
$255.83
|
| Rate for Payer: Humana ChoiceCare |
$240.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$250.27
|
| Rate for Payer: PHCS All Commercial |
$208.56
|
| Rate for Payer: PHP All Commercial |
$210.90
|
| Rate for Payer: Sagamore Health Network All Products |
$214.68
|
| Rate for Payer: Signature Care EPO |
$230.81
|
| Rate for Payer: Signature Care PPO |
$244.71
|
| Rate for Payer: United Healthcare Commercial |
$219.13
|
|
|
HC X-RAY-WRIST 2 VIEWS BI
|
Facility
|
OP
|
$556.16
|
|
|
Service Code
|
CPT 73100 50
|
| Hospital Charge Code |
21613100
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$15.77 |
| Max. Negotiated Rate |
$517.23 |
| Rate for Payer: Aetna Commercial |
$469.40
|
| Rate for Payer: Aetna Medicare |
$177.97
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$15.77
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$172.41
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$319.40
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$347.66
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$15.77
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$204.67
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$195.77
|
| Rate for Payer: Cash Price |
$333.70
|
| Rate for Payer: Cash Price |
$333.70
|
| Rate for Payer: Centivo All Commercial |
$302.55
|
| Rate for Payer: Cigna All Commercial |
$479.97
|
| Rate for Payer: CORVEL All Commercial |
$517.23
|
| Rate for Payer: Coventry All Commercial |
$489.42
|
| Rate for Payer: Encore All Commercial |
$511.95
|
| Rate for Payer: Frontpath All Commercial |
$511.67
|
| Rate for Payer: Humana ChoiceCare |
$480.36
|
| Rate for Payer: Humana Medicare |
$177.97
|
| Rate for Payer: Lucent All Commercial |
$302.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$500.54
|
| Rate for Payer: Managed Health Services Medicaid |
$15.77
|
| Rate for Payer: MDWise Medicaid |
$15.77
|
| Rate for Payer: PHCS All Commercial |
$417.12
|
| Rate for Payer: PHP All Commercial |
$421.79
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$216.90
|
| Rate for Payer: Sagamore Health Network All Products |
$429.36
|
| Rate for Payer: Signature Care EPO |
$461.61
|
| Rate for Payer: Signature Care PPO |
$489.42
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$472.74
|
| Rate for Payer: United Healthcare Commercial |
$438.25
|
| Rate for Payer: United Healthcare Medicare |
$177.97
|
|
|
HC X-RAY-WRIST 2 VIEWS BI
|
Facility
|
IP
|
$556.16
|
|
|
Service Code
|
CPT 73100 50
|
| Hospital Charge Code |
21613100
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$417.12 |
| Max. Negotiated Rate |
$517.23 |
| Rate for Payer: Aetna Commercial |
$480.52
|
| Rate for Payer: Cash Price |
$333.70
|
| Rate for Payer: Cigna All Commercial |
$479.97
|
| Rate for Payer: CORVEL All Commercial |
$517.23
|
| Rate for Payer: Coventry All Commercial |
$489.42
|
| Rate for Payer: Encore All Commercial |
$511.95
|
| Rate for Payer: Frontpath All Commercial |
$511.67
|
| Rate for Payer: Humana ChoiceCare |
$480.36
|
| Rate for Payer: Lutheran Preferred All Commercial |
$500.54
|
| Rate for Payer: PHCS All Commercial |
$417.12
|
| Rate for Payer: PHP All Commercial |
$421.79
|
| Rate for Payer: Sagamore Health Network All Products |
$429.36
|
| Rate for Payer: Signature Care EPO |
$461.61
|
| Rate for Payer: Signature Care PPO |
$489.42
|
| Rate for Payer: United Healthcare Commercial |
$438.25
|
|
|
HC X-RAY-WRIST 2 VIEWS LT
|
Facility
|
IP
|
$370.79
|
|
|
Service Code
|
CPT 73100 LT
|
| Hospital Charge Code |
1613100
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$278.09 |
| Max. Negotiated Rate |
$344.83 |
| Rate for Payer: Aetna Commercial |
$320.36
|
| Rate for Payer: Cash Price |
$222.47
|
| Rate for Payer: Cigna All Commercial |
$319.99
|
| Rate for Payer: CORVEL All Commercial |
$344.83
|
| Rate for Payer: Coventry All Commercial |
$326.30
|
| Rate for Payer: Encore All Commercial |
$341.31
|
| Rate for Payer: Frontpath All Commercial |
$341.13
|
| Rate for Payer: Humana ChoiceCare |
$320.25
|
| Rate for Payer: Lutheran Preferred All Commercial |
$333.71
|
| Rate for Payer: PHCS All Commercial |
$278.09
|
| Rate for Payer: PHP All Commercial |
$281.21
|
| Rate for Payer: Sagamore Health Network All Products |
$286.25
|
| Rate for Payer: Signature Care EPO |
$307.76
|
| Rate for Payer: Signature Care PPO |
$326.30
|
| Rate for Payer: United Healthcare Commercial |
$292.18
|
|
|
HC X-RAY-WRIST 2 VIEWS LT
|
Facility
|
OP
|
$370.79
|
|
|
Service Code
|
CPT 73100 LT
|
| Hospital Charge Code |
1613100
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$15.77 |
| Max. Negotiated Rate |
$344.83 |
| Rate for Payer: Aetna Commercial |
$312.95
|
| Rate for Payer: Aetna Medicare |
$118.65
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$15.77
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$114.94
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$212.94
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$231.78
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$15.77
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$136.45
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$130.52
|
| Rate for Payer: Cash Price |
$222.47
|
| Rate for Payer: Cash Price |
$222.47
|
| Rate for Payer: Centivo All Commercial |
$201.71
|
| Rate for Payer: Cigna All Commercial |
$319.99
|
| Rate for Payer: CORVEL All Commercial |
$344.83
|
| Rate for Payer: Coventry All Commercial |
$326.30
|
| Rate for Payer: Encore All Commercial |
$341.31
|
| Rate for Payer: Frontpath All Commercial |
$341.13
|
| Rate for Payer: Humana ChoiceCare |
$320.25
|
| Rate for Payer: Humana Medicare |
$118.65
|
| Rate for Payer: Lucent All Commercial |
$201.71
|
| Rate for Payer: Lutheran Preferred All Commercial |
$333.71
|
| Rate for Payer: Managed Health Services Medicaid |
$15.77
|
| Rate for Payer: MDWise Medicaid |
$15.77
|
| Rate for Payer: PHCS All Commercial |
$278.09
|
| Rate for Payer: PHP All Commercial |
$281.21
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$144.61
|
| Rate for Payer: Sagamore Health Network All Products |
$286.25
|
| Rate for Payer: Signature Care EPO |
$307.76
|
| Rate for Payer: Signature Care PPO |
$326.30
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$315.17
|
| Rate for Payer: United Healthcare Commercial |
$292.18
|
| Rate for Payer: United Healthcare Medicare |
$118.65
|
|
|
HC X-RAY-WRIST 2 VIEWS RT
|
Facility
|
OP
|
$370.79
|
|
|
Service Code
|
CPT 73100 RT
|
| Hospital Charge Code |
11613100
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$15.77 |
| Max. Negotiated Rate |
$344.83 |
| Rate for Payer: Aetna Commercial |
$312.95
|
| Rate for Payer: Aetna Medicare |
$118.65
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$15.77
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$114.94
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$212.94
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$231.78
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$15.77
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$136.45
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$130.52
|
| Rate for Payer: Cash Price |
$222.47
|
| Rate for Payer: Cash Price |
$222.47
|
| Rate for Payer: Centivo All Commercial |
$201.71
|
| Rate for Payer: Cigna All Commercial |
$319.99
|
| Rate for Payer: CORVEL All Commercial |
$344.83
|
| Rate for Payer: Coventry All Commercial |
$326.30
|
| Rate for Payer: Encore All Commercial |
$341.31
|
| Rate for Payer: Frontpath All Commercial |
$341.13
|
| Rate for Payer: Humana ChoiceCare |
$320.25
|
| Rate for Payer: Humana Medicare |
$118.65
|
| Rate for Payer: Lucent All Commercial |
$201.71
|
| Rate for Payer: Lutheran Preferred All Commercial |
$333.71
|
| Rate for Payer: Managed Health Services Medicaid |
$15.77
|
| Rate for Payer: MDWise Medicaid |
$15.77
|
| Rate for Payer: PHCS All Commercial |
$278.09
|
| Rate for Payer: PHP All Commercial |
$281.21
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$144.61
|
| Rate for Payer: Sagamore Health Network All Products |
$286.25
|
| Rate for Payer: Signature Care EPO |
$307.76
|
| Rate for Payer: Signature Care PPO |
$326.30
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$315.17
|
| Rate for Payer: United Healthcare Commercial |
$292.18
|
| Rate for Payer: United Healthcare Medicare |
$118.65
|
|
|
HC X-RAY-WRIST 2 VIEWS RT
|
Facility
|
IP
|
$370.79
|
|
|
Service Code
|
CPT 73100 RT
|
| Hospital Charge Code |
11613100
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$278.09 |
| Max. Negotiated Rate |
$344.83 |
| Rate for Payer: Aetna Commercial |
$320.36
|
| Rate for Payer: Cash Price |
$222.47
|
| Rate for Payer: Cigna All Commercial |
$319.99
|
| Rate for Payer: CORVEL All Commercial |
$344.83
|
| Rate for Payer: Coventry All Commercial |
$326.30
|
| Rate for Payer: Encore All Commercial |
$341.31
|
| Rate for Payer: Frontpath All Commercial |
$341.13
|
| Rate for Payer: Humana ChoiceCare |
$320.25
|
| Rate for Payer: Lutheran Preferred All Commercial |
$333.71
|
| Rate for Payer: PHCS All Commercial |
$278.09
|
| Rate for Payer: PHP All Commercial |
$281.21
|
| Rate for Payer: Sagamore Health Network All Products |
$286.25
|
| Rate for Payer: Signature Care EPO |
$307.76
|
| Rate for Payer: Signature Care PPO |
$326.30
|
| Rate for Payer: United Healthcare Commercial |
$292.18
|
|
|
HC X-RAY-WRIST 3 VIEWS BI
|
Facility
|
OP
|
$621.57
|
|
|
Service Code
|
CPT 73110 50
|
| Hospital Charge Code |
21613110
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$20.48 |
| Max. Negotiated Rate |
$578.06 |
| Rate for Payer: Aetna Commercial |
$524.61
|
| Rate for Payer: Aetna Medicare |
$198.90
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$20.48
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$192.69
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$356.97
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$388.54
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$20.48
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$228.74
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$218.79
|
| Rate for Payer: Cash Price |
$372.94
|
| Rate for Payer: Cash Price |
$372.94
|
| Rate for Payer: Centivo All Commercial |
$338.13
|
| Rate for Payer: Cigna All Commercial |
$536.41
|
| Rate for Payer: CORVEL All Commercial |
$578.06
|
| Rate for Payer: Coventry All Commercial |
$546.98
|
| Rate for Payer: Encore All Commercial |
$572.16
|
| Rate for Payer: Frontpath All Commercial |
$571.84
|
| Rate for Payer: Humana ChoiceCare |
$536.85
|
| Rate for Payer: Humana Medicare |
$198.90
|
| Rate for Payer: Lucent All Commercial |
$338.13
|
| Rate for Payer: Lutheran Preferred All Commercial |
$559.41
|
| Rate for Payer: Managed Health Services Medicaid |
$20.48
|
| Rate for Payer: MDWise Medicaid |
$20.48
|
| Rate for Payer: PHCS All Commercial |
$466.18
|
| Rate for Payer: PHP All Commercial |
$471.40
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$242.41
|
| Rate for Payer: Sagamore Health Network All Products |
$479.85
|
| Rate for Payer: Signature Care EPO |
$515.90
|
| Rate for Payer: Signature Care PPO |
$546.98
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$528.33
|
| Rate for Payer: United Healthcare Commercial |
$489.80
|
| Rate for Payer: United Healthcare Medicare |
$198.90
|
|
|
HC X-RAY-WRIST 3 VIEWS BI
|
Facility
|
IP
|
$621.57
|
|
|
Service Code
|
CPT 73110 50
|
| Hospital Charge Code |
21613110
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$466.18 |
| Max. Negotiated Rate |
$578.06 |
| Rate for Payer: Aetna Commercial |
$537.04
|
| Rate for Payer: Cash Price |
$372.94
|
| Rate for Payer: Cigna All Commercial |
$536.41
|
| Rate for Payer: CORVEL All Commercial |
$578.06
|
| Rate for Payer: Coventry All Commercial |
$546.98
|
| Rate for Payer: Encore All Commercial |
$572.16
|
| Rate for Payer: Frontpath All Commercial |
$571.84
|
| Rate for Payer: Humana ChoiceCare |
$536.85
|
| Rate for Payer: Lutheran Preferred All Commercial |
$559.41
|
| Rate for Payer: PHCS All Commercial |
$466.18
|
| Rate for Payer: PHP All Commercial |
$471.40
|
| Rate for Payer: Sagamore Health Network All Products |
$479.85
|
| Rate for Payer: Signature Care EPO |
$515.90
|
| Rate for Payer: Signature Care PPO |
$546.98
|
| Rate for Payer: United Healthcare Commercial |
$489.80
|
|
|
HC X-RAY-WRIST 3 VIEWS LT
|
Facility
|
IP
|
$414.39
|
|
|
Service Code
|
CPT 73110 LT
|
| Hospital Charge Code |
1613110
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$310.79 |
| Max. Negotiated Rate |
$385.38 |
| Rate for Payer: Aetna Commercial |
$358.03
|
| Rate for Payer: Cash Price |
$248.63
|
| Rate for Payer: Cigna All Commercial |
$357.62
|
| Rate for Payer: CORVEL All Commercial |
$385.38
|
| Rate for Payer: Coventry All Commercial |
$364.66
|
| Rate for Payer: Encore All Commercial |
$381.45
|
| Rate for Payer: Frontpath All Commercial |
$381.24
|
| Rate for Payer: Humana ChoiceCare |
$357.91
|
| Rate for Payer: Lutheran Preferred All Commercial |
$372.95
|
| Rate for Payer: PHCS All Commercial |
$310.79
|
| Rate for Payer: PHP All Commercial |
$314.27
|
| Rate for Payer: Sagamore Health Network All Products |
$319.91
|
| Rate for Payer: Signature Care EPO |
$343.94
|
| Rate for Payer: Signature Care PPO |
$364.66
|
| Rate for Payer: United Healthcare Commercial |
$326.54
|
|
|
HC X-RAY-WRIST 3 VIEWS LT
|
Facility
|
OP
|
$414.39
|
|
|
Service Code
|
CPT 73110 LT
|
| Hospital Charge Code |
1613110
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$20.48 |
| Max. Negotiated Rate |
$385.38 |
| Rate for Payer: Aetna Commercial |
$349.75
|
| Rate for Payer: Aetna Medicare |
$132.60
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$20.48
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$128.46
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$237.98
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$259.04
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$20.48
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$152.50
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$145.87
|
| Rate for Payer: Cash Price |
$248.63
|
| Rate for Payer: Cash Price |
$248.63
|
| Rate for Payer: Centivo All Commercial |
$225.43
|
| Rate for Payer: Cigna All Commercial |
$357.62
|
| Rate for Payer: CORVEL All Commercial |
$385.38
|
| Rate for Payer: Coventry All Commercial |
$364.66
|
| Rate for Payer: Encore All Commercial |
$381.45
|
| Rate for Payer: Frontpath All Commercial |
$381.24
|
| Rate for Payer: Humana ChoiceCare |
$357.91
|
| Rate for Payer: Humana Medicare |
$132.60
|
| Rate for Payer: Lucent All Commercial |
$225.43
|
| Rate for Payer: Lutheran Preferred All Commercial |
$372.95
|
| Rate for Payer: Managed Health Services Medicaid |
$20.48
|
| Rate for Payer: MDWise Medicaid |
$20.48
|
| Rate for Payer: PHCS All Commercial |
$310.79
|
| Rate for Payer: PHP All Commercial |
$314.27
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$161.61
|
| Rate for Payer: Sagamore Health Network All Products |
$319.91
|
| Rate for Payer: Signature Care EPO |
$343.94
|
| Rate for Payer: Signature Care PPO |
$364.66
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$352.23
|
| Rate for Payer: United Healthcare Commercial |
$326.54
|
| Rate for Payer: United Healthcare Medicare |
$132.60
|
|
|
HC X-RAY-WRIST 3 VIEWS RT
|
Facility
|
OP
|
$414.39
|
|
|
Service Code
|
CPT 73110 RT
|
| Hospital Charge Code |
11613110
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$20.48 |
| Max. Negotiated Rate |
$385.38 |
| Rate for Payer: Aetna Commercial |
$349.75
|
| Rate for Payer: Aetna Medicare |
$132.60
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$20.48
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$128.46
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$237.98
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$259.04
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$20.48
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$152.50
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$145.87
|
| Rate for Payer: Cash Price |
$248.63
|
| Rate for Payer: Cash Price |
$248.63
|
| Rate for Payer: Centivo All Commercial |
$225.43
|
| Rate for Payer: Cigna All Commercial |
$357.62
|
| Rate for Payer: CORVEL All Commercial |
$385.38
|
| Rate for Payer: Coventry All Commercial |
$364.66
|
| Rate for Payer: Encore All Commercial |
$381.45
|
| Rate for Payer: Frontpath All Commercial |
$381.24
|
| Rate for Payer: Humana ChoiceCare |
$357.91
|
| Rate for Payer: Humana Medicare |
$132.60
|
| Rate for Payer: Lucent All Commercial |
$225.43
|
| Rate for Payer: Lutheran Preferred All Commercial |
$372.95
|
| Rate for Payer: Managed Health Services Medicaid |
$20.48
|
| Rate for Payer: MDWise Medicaid |
$20.48
|
| Rate for Payer: PHCS All Commercial |
$310.79
|
| Rate for Payer: PHP All Commercial |
$314.27
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$161.61
|
| Rate for Payer: Sagamore Health Network All Products |
$319.91
|
| Rate for Payer: Signature Care EPO |
$343.94
|
| Rate for Payer: Signature Care PPO |
$364.66
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$352.23
|
| Rate for Payer: United Healthcare Commercial |
$326.54
|
| Rate for Payer: United Healthcare Medicare |
$132.60
|
|
|
HC X-RAY-WRIST 3 VIEWS RT
|
Facility
|
IP
|
$414.39
|
|
|
Service Code
|
CPT 73110 RT
|
| Hospital Charge Code |
11613110
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$310.79 |
| Max. Negotiated Rate |
$385.38 |
| Rate for Payer: Aetna Commercial |
$358.03
|
| Rate for Payer: Cash Price |
$248.63
|
| Rate for Payer: Cigna All Commercial |
$357.62
|
| Rate for Payer: CORVEL All Commercial |
$385.38
|
| Rate for Payer: Coventry All Commercial |
$364.66
|
| Rate for Payer: Encore All Commercial |
$381.45
|
| Rate for Payer: Frontpath All Commercial |
$381.24
|
| Rate for Payer: Humana ChoiceCare |
$357.91
|
| Rate for Payer: Lutheran Preferred All Commercial |
$372.95
|
| Rate for Payer: PHCS All Commercial |
$310.79
|
| Rate for Payer: PHP All Commercial |
$314.27
|
| Rate for Payer: Sagamore Health Network All Products |
$319.91
|
| Rate for Payer: Signature Care EPO |
$343.94
|
| Rate for Payer: Signature Care PPO |
$364.66
|
| Rate for Payer: United Healthcare Commercial |
$326.54
|
|
|
HC Z1 CV COL CMTLESS SZ 0
|
Facility
|
OP
|
$16,110.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
41608476
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.40 |
| Max. Negotiated Rate |
$14,982.30 |
| Rate for Payer: Aetna Commercial |
$13,596.84
|
| Rate for Payer: Aetna Medicare |
$5,155.20
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$134.40
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$4,994.10
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$9,251.97
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$10,070.36
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$134.40
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$5,928.48
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$5,670.72
|
| Rate for Payer: Cash Price |
$9,666.00
|
| Rate for Payer: Cash Price |
$9,666.00
|
| Rate for Payer: Centivo All Commercial |
$8,763.84
|
| Rate for Payer: Cigna All Commercial |
$13,902.93
|
| Rate for Payer: CORVEL All Commercial |
$14,982.30
|
| Rate for Payer: Coventry All Commercial |
$14,176.80
|
| Rate for Payer: Encore All Commercial |
$14,829.25
|
| Rate for Payer: Frontpath All Commercial |
$14,821.20
|
| Rate for Payer: Humana ChoiceCare |
$13,914.21
|
| Rate for Payer: Humana Medicare |
$5,155.20
|
| Rate for Payer: Lucent All Commercial |
$8,763.84
|
| Rate for Payer: Lutheran Preferred All Commercial |
$14,499.00
|
| Rate for Payer: Managed Health Services Medicaid |
$134.40
|
| Rate for Payer: MDWise Medicaid |
$134.40
|
| Rate for Payer: PHCS All Commercial |
$12,082.50
|
| Rate for Payer: PHP All Commercial |
$12,217.82
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$6,282.90
|
| Rate for Payer: Sagamore Health Network All Products |
$12,436.92
|
| Rate for Payer: Signature Care EPO |
$13,371.30
|
| Rate for Payer: Signature Care PPO |
$14,176.80
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$13,693.50
|
| Rate for Payer: United Healthcare Commercial |
$12,694.68
|
| Rate for Payer: United Healthcare Medicare |
$5,155.20
|
|
|
HC Z1 CV COL CMTLESS SZ 0
|
Facility
|
IP
|
$16,110.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
41608476
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$12,082.50 |
| Max. Negotiated Rate |
$14,982.30 |
| Rate for Payer: Aetna Commercial |
$13,919.04
|
| Rate for Payer: Cash Price |
$9,666.00
|
| Rate for Payer: Cigna All Commercial |
$13,902.93
|
| Rate for Payer: CORVEL All Commercial |
$14,982.30
|
| Rate for Payer: Coventry All Commercial |
$14,176.80
|
| Rate for Payer: Encore All Commercial |
$14,829.25
|
| Rate for Payer: Frontpath All Commercial |
$14,821.20
|
| Rate for Payer: Humana ChoiceCare |
$13,914.21
|
| Rate for Payer: Lutheran Preferred All Commercial |
$14,499.00
|
| Rate for Payer: PHCS All Commercial |
$12,082.50
|
| Rate for Payer: PHP All Commercial |
$12,217.82
|
| Rate for Payer: Sagamore Health Network All Products |
$12,436.92
|
| Rate for Payer: Signature Care EPO |
$13,371.30
|
| Rate for Payer: Signature Care PPO |
$14,176.80
|
| Rate for Payer: United Healthcare Commercial |
$12,694.68
|
|
|
HC Z1 CV COL CMTLESS SZ 1
|
Facility
|
IP
|
$16,110.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
41608477
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$12,082.50 |
| Max. Negotiated Rate |
$14,982.30 |
| Rate for Payer: Aetna Commercial |
$13,919.04
|
| Rate for Payer: Cash Price |
$9,666.00
|
| Rate for Payer: Cigna All Commercial |
$13,902.93
|
| Rate for Payer: CORVEL All Commercial |
$14,982.30
|
| Rate for Payer: Coventry All Commercial |
$14,176.80
|
| Rate for Payer: Encore All Commercial |
$14,829.25
|
| Rate for Payer: Frontpath All Commercial |
$14,821.20
|
| Rate for Payer: Humana ChoiceCare |
$13,914.21
|
| Rate for Payer: Lutheran Preferred All Commercial |
$14,499.00
|
| Rate for Payer: PHCS All Commercial |
$12,082.50
|
| Rate for Payer: PHP All Commercial |
$12,217.82
|
| Rate for Payer: Sagamore Health Network All Products |
$12,436.92
|
| Rate for Payer: Signature Care EPO |
$13,371.30
|
| Rate for Payer: Signature Care PPO |
$14,176.80
|
| Rate for Payer: United Healthcare Commercial |
$12,694.68
|
|
