|
INTMD RPR N-HF/GENIT7.6-12.5
|
Professional
|
Both
|
$2,040.00
|
|
|
Service Code
|
HCPCS 12044
|
| Hospital Charge Code |
76100140
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$107.97 |
| Max. Negotiated Rate |
$1,224.00 |
| Rate for Payer: Aetna Commercial |
$303.34
|
| Rate for Payer: Ambetter Exchange |
$202.32
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$107.97
|
| Rate for Payer: Anthem Medicaid |
$138.25
|
| Rate for Payer: Buckeye Individual/Medicaid |
$202.32
|
| Rate for Payer: Buckeye Medicare Advantage |
$202.32
|
| Rate for Payer: CareSource Just4Me Medicare |
$242.78
|
| Rate for Payer: Cash Price |
$1,020.00
|
| Rate for Payer: Cash Price |
$1,020.00
|
| Rate for Payer: Cigna Commercial |
$276.17
|
| Rate for Payer: Healthspan PPO |
$366.66
|
| Rate for Payer: Humana Medicaid |
$138.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$264.64
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$202.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$202.32
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$141.01
|
| Rate for Payer: Molina Healthcare Passport |
$138.25
|
| Rate for Payer: Multiplan PHCS |
$1,224.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$263.02
|
| Rate for Payer: UHCCP Medicaid |
$113.37
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$139.63
|
| Rate for Payer: Wellcare Medicare Advantage |
$202.32
|
|
|
INTMD RPR N-HF/GENIT7.6-12.5
|
Facility
|
OP
|
$1,140.00
|
|
|
Service Code
|
HCPCS 12044
|
| Hospital Charge Code |
45000063
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$392.05 |
| Max. Negotiated Rate |
$1,094.40 |
| Rate for Payer: Aetna Commercial |
$877.80
|
| Rate for Payer: Anthem Medicaid |
$392.05
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$565.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$889.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$791.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$763.56
|
| Rate for Payer: Cash Price |
$570.00
|
| Rate for Payer: Cash Price |
$570.00
|
| Rate for Payer: Cigna Commercial |
$946.20
|
| Rate for Payer: First Health Commercial |
$1,083.00
|
| Rate for Payer: Humana Commercial |
$969.00
|
| Rate for Payer: Humana KY Medicaid |
$392.05
|
| Rate for Payer: Humana Medicare Advantage |
$565.60
|
| Rate for Payer: Kentucky WC Medicaid |
$396.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$934.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$841.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$678.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$399.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,003.20
|
| Rate for Payer: Ohio Health Group HMO |
$855.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$912.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$991.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$786.60
|
| Rate for Payer: PHCS Commercial |
$1,094.40
|
| Rate for Payer: United Healthcare All Payer |
$1,003.20
|
|
|
INTMD RPR N-HF/GENIT7.6-12.5
|
Facility
|
OP
|
$2,040.00
|
|
|
Service Code
|
HCPCS 12044
|
| Hospital Charge Code |
76100140
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$565.60 |
| Max. Negotiated Rate |
$1,958.40 |
| Rate for Payer: Aetna Commercial |
$1,570.80
|
| Rate for Payer: Anthem Medicaid |
$701.56
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$565.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,591.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$791.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$763.56
|
| Rate for Payer: Cash Price |
$1,020.00
|
| Rate for Payer: Cash Price |
$1,020.00
|
| Rate for Payer: Cigna Commercial |
$1,693.20
|
| Rate for Payer: First Health Commercial |
$1,938.00
|
| Rate for Payer: Humana Commercial |
$1,734.00
|
| Rate for Payer: Humana KY Medicaid |
$701.56
|
| Rate for Payer: Humana Medicare Advantage |
$565.60
|
| Rate for Payer: Kentucky WC Medicaid |
$708.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,672.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,505.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$678.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$715.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,795.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,530.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,632.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,774.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,407.60
|
| Rate for Payer: PHCS Commercial |
$1,958.40
|
| Rate for Payer: United Healthcare All Payer |
$1,795.20
|
|
|
INTMD RPR N-HF/GENIT7.6-12.5
|
Facility
|
IP
|
$1,140.00
|
|
|
Service Code
|
HCPCS 12044
|
| Hospital Charge Code |
45000063
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$342.00 |
| Max. Negotiated Rate |
$1,094.40 |
| Rate for Payer: Aetna Commercial |
$877.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$889.20
|
| Rate for Payer: Cash Price |
$570.00
|
| Rate for Payer: Cigna Commercial |
$946.20
|
| Rate for Payer: First Health Commercial |
$1,083.00
|
| Rate for Payer: Humana Commercial |
$969.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$934.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$841.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$342.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,003.20
|
| Rate for Payer: Ohio Health Group HMO |
$855.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$912.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$991.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$786.60
|
| Rate for Payer: PHCS Commercial |
$1,094.40
|
| Rate for Payer: United Healthcare All Payer |
$1,003.20
|
|
|
INTMD RPR N-HF/GENIT7.6-12.(P
|
Professional
|
Both
|
$900.00
|
|
|
Service Code
|
HCPCS 12044
|
| Hospital Charge Code |
761P0140
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$107.97 |
| Max. Negotiated Rate |
$540.00 |
| Rate for Payer: Aetna Commercial |
$303.34
|
| Rate for Payer: Ambetter Exchange |
$202.32
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$107.97
|
| Rate for Payer: Anthem Medicaid |
$138.25
|
| Rate for Payer: Buckeye Individual/Medicaid |
$202.32
|
| Rate for Payer: Buckeye Medicare Advantage |
$202.32
|
| Rate for Payer: CareSource Just4Me Medicare |
$242.78
|
| Rate for Payer: Cash Price |
$450.00
|
| Rate for Payer: Cash Price |
$450.00
|
| Rate for Payer: Cigna Commercial |
$276.17
|
| Rate for Payer: Healthspan PPO |
$366.66
|
| Rate for Payer: Humana Medicaid |
$138.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$264.64
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$202.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$202.32
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$141.01
|
| Rate for Payer: Molina Healthcare Passport |
$138.25
|
| Rate for Payer: Multiplan PHCS |
$540.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$263.02
|
| Rate for Payer: UHCCP Medicaid |
$113.37
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$139.63
|
| Rate for Payer: Wellcare Medicare Advantage |
$202.32
|
|
|
INTMD RPR N-HF/GENIT7.6-12.(T
|
Facility
|
IP
|
$1,140.00
|
|
|
Service Code
|
HCPCS 12044
|
| Hospital Charge Code |
761T0140
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$342.00 |
| Max. Negotiated Rate |
$1,094.40 |
| Rate for Payer: Aetna Commercial |
$877.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$889.20
|
| Rate for Payer: Cash Price |
$570.00
|
| Rate for Payer: Cigna Commercial |
$946.20
|
| Rate for Payer: First Health Commercial |
$1,083.00
|
| Rate for Payer: Humana Commercial |
$969.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$934.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$841.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$342.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,003.20
|
| Rate for Payer: Ohio Health Group HMO |
$855.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$912.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$991.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$786.60
|
| Rate for Payer: PHCS Commercial |
$1,094.40
|
| Rate for Payer: United Healthcare All Payer |
$1,003.20
|
|
|
INTMD RPR N-HF/GENIT7.6-12.(T
|
Facility
|
OP
|
$1,140.00
|
|
|
Service Code
|
HCPCS 12044
|
| Hospital Charge Code |
761T0140
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$392.05 |
| Max. Negotiated Rate |
$1,094.40 |
| Rate for Payer: Aetna Commercial |
$877.80
|
| Rate for Payer: Anthem Medicaid |
$392.05
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$565.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$889.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$791.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$763.56
|
| Rate for Payer: Cash Price |
$570.00
|
| Rate for Payer: Cash Price |
$570.00
|
| Rate for Payer: Cigna Commercial |
$946.20
|
| Rate for Payer: First Health Commercial |
$1,083.00
|
| Rate for Payer: Humana Commercial |
$969.00
|
| Rate for Payer: Humana KY Medicaid |
$392.05
|
| Rate for Payer: Humana Medicare Advantage |
$565.60
|
| Rate for Payer: Kentucky WC Medicaid |
$396.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$934.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$841.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$678.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$399.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,003.20
|
| Rate for Payer: Ohio Health Group HMO |
$855.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$912.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$991.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$786.60
|
| Rate for Payer: PHCS Commercial |
$1,094.40
|
| Rate for Payer: United Healthcare All Payer |
$1,003.20
|
|
|
INTMD RPR S/A/T/EXT 20.1-30
|
Professional
|
Both
|
$535.00
|
|
|
Service Code
|
HCPCS 12036
|
| Hospital Charge Code |
761P2581
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$144.66 |
| Max. Negotiated Rate |
$448.52 |
| Rate for Payer: Aetna Commercial |
$398.24
|
| Rate for Payer: Ambetter Exchange |
$267.23
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$144.66
|
| Rate for Payer: Anthem Medicaid |
$188.59
|
| Rate for Payer: Buckeye Individual/Medicaid |
$267.23
|
| Rate for Payer: Buckeye Medicare Advantage |
$267.23
|
| Rate for Payer: CareSource Just4Me Medicare |
$320.68
|
| Rate for Payer: Cash Price |
$267.50
|
| Rate for Payer: Cash Price |
$267.50
|
| Rate for Payer: Cigna Commercial |
$382.89
|
| Rate for Payer: Healthspan PPO |
$448.52
|
| Rate for Payer: Humana Medicaid |
$188.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$338.37
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$267.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$267.23
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$192.36
|
| Rate for Payer: Molina Healthcare Passport |
$188.59
|
| Rate for Payer: Multiplan PHCS |
$321.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$347.40
|
| Rate for Payer: UHCCP Medicaid |
$151.89
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$190.48
|
| Rate for Payer: Wellcare Medicare Advantage |
$267.23
|
|
|
INTMD RPR S/A/T/EXT 20.1-30
|
Professional
|
Both
|
$1,277.00
|
|
|
Service Code
|
HCPCS 12036
|
| Hospital Charge Code |
76102581
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$144.66 |
| Max. Negotiated Rate |
$766.20 |
| Rate for Payer: Aetna Commercial |
$398.24
|
| Rate for Payer: Ambetter Exchange |
$267.23
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$144.66
|
| Rate for Payer: Anthem Medicaid |
$188.59
|
| Rate for Payer: Buckeye Individual/Medicaid |
$267.23
|
| Rate for Payer: Buckeye Medicare Advantage |
$267.23
|
| Rate for Payer: CareSource Just4Me Medicare |
$320.68
|
| Rate for Payer: Cash Price |
$638.50
|
| Rate for Payer: Cash Price |
$638.50
|
| Rate for Payer: Cigna Commercial |
$382.89
|
| Rate for Payer: Healthspan PPO |
$448.52
|
| Rate for Payer: Humana Medicaid |
$188.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$338.37
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$267.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$267.23
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$192.36
|
| Rate for Payer: Molina Healthcare Passport |
$188.59
|
| Rate for Payer: Multiplan PHCS |
$766.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$347.40
|
| Rate for Payer: UHCCP Medicaid |
$151.89
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$190.48
|
| Rate for Payer: Wellcare Medicare Advantage |
$267.23
|
|
|
INTMD RPR S/A/T/EXT 20.1-30
|
Facility
|
IP
|
$1,277.00
|
|
|
Service Code
|
HCPCS 12036
|
| Hospital Charge Code |
76102581
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$383.10 |
| Max. Negotiated Rate |
$1,225.92 |
| Rate for Payer: Aetna Commercial |
$983.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$996.06
|
| Rate for Payer: Cash Price |
$638.50
|
| Rate for Payer: Cigna Commercial |
$1,059.91
|
| Rate for Payer: First Health Commercial |
$1,213.15
|
| Rate for Payer: Humana Commercial |
$1,085.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,047.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$942.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$383.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,123.76
|
| Rate for Payer: Ohio Health Group HMO |
$957.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,021.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,110.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$881.13
|
| Rate for Payer: PHCS Commercial |
$1,225.92
|
| Rate for Payer: United Healthcare All Payer |
$1,123.76
|
|
|
INTMD RPR S/A/T/EXT 20.1-30
|
Facility
|
OP
|
$1,277.00
|
|
|
Service Code
|
HCPCS 12036
|
| Hospital Charge Code |
76102581
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$439.16 |
| Max. Negotiated Rate |
$1,225.92 |
| Rate for Payer: Aetna Commercial |
$983.29
|
| Rate for Payer: Anthem Medicaid |
$439.16
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$565.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$996.06
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$791.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$763.56
|
| Rate for Payer: Cash Price |
$638.50
|
| Rate for Payer: Cash Price |
$638.50
|
| Rate for Payer: Cigna Commercial |
$1,059.91
|
| Rate for Payer: First Health Commercial |
$1,213.15
|
| Rate for Payer: Humana Commercial |
$1,085.45
|
| Rate for Payer: Humana KY Medicaid |
$439.16
|
| Rate for Payer: Humana Medicare Advantage |
$565.60
|
| Rate for Payer: Kentucky WC Medicaid |
$443.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,047.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$942.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$678.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$447.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,123.76
|
| Rate for Payer: Ohio Health Group HMO |
$957.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,021.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,110.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$881.13
|
| Rate for Payer: PHCS Commercial |
$1,225.92
|
| Rate for Payer: United Healthcare All Payer |
$1,123.76
|
|
|
INTMD RPR S/A/T/EXT 20.1-30
|
Facility
|
OP
|
$742.00
|
|
|
Service Code
|
HCPCS 12036
|
| Hospital Charge Code |
761T2581
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$255.17 |
| Max. Negotiated Rate |
$791.84 |
| Rate for Payer: Aetna Commercial |
$571.34
|
| Rate for Payer: Anthem Medicaid |
$255.17
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$565.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$578.76
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$791.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$763.56
|
| Rate for Payer: Cash Price |
$371.00
|
| Rate for Payer: Cash Price |
$371.00
|
| Rate for Payer: Cigna Commercial |
$615.86
|
| Rate for Payer: First Health Commercial |
$704.90
|
| Rate for Payer: Humana Commercial |
$630.70
|
| Rate for Payer: Humana KY Medicaid |
$255.17
|
| Rate for Payer: Humana Medicare Advantage |
$565.60
|
| Rate for Payer: Kentucky WC Medicaid |
$257.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$608.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$547.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$678.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$260.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$652.96
|
| Rate for Payer: Ohio Health Group HMO |
$556.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$593.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$645.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$511.98
|
| Rate for Payer: PHCS Commercial |
$712.32
|
| Rate for Payer: United Healthcare All Payer |
$652.96
|
|
|
INTMD RPR S/A/T/EXT 20.1-30
|
Facility
|
IP
|
$742.00
|
|
|
Service Code
|
HCPCS 12036
|
| Hospital Charge Code |
761T2581
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$222.60 |
| Max. Negotiated Rate |
$712.32 |
| Rate for Payer: Aetna Commercial |
$571.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$578.76
|
| Rate for Payer: Cash Price |
$371.00
|
| Rate for Payer: Cigna Commercial |
$615.86
|
| Rate for Payer: First Health Commercial |
$704.90
|
| Rate for Payer: Humana Commercial |
$630.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$608.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$547.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$222.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$652.96
|
| Rate for Payer: Ohio Health Group HMO |
$556.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$593.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$645.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$511.98
|
| Rate for Payer: PHCS Commercial |
$712.32
|
| Rate for Payer: United Healthcare All Payer |
$652.96
|
|
|
INTMD RPR S/TR/EXT >30.0 CM
|
Facility
|
IP
|
$3,053.00
|
|
|
Service Code
|
HCPCS 12037
|
| Hospital Charge Code |
76102582
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$915.90 |
| Max. Negotiated Rate |
$2,930.88 |
| Rate for Payer: Aetna Commercial |
$2,350.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,381.34
|
| Rate for Payer: Cash Price |
$1,526.50
|
| Rate for Payer: Cigna Commercial |
$2,533.99
|
| Rate for Payer: First Health Commercial |
$2,900.35
|
| Rate for Payer: Humana Commercial |
$2,595.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,503.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,253.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$915.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,686.64
|
| Rate for Payer: Ohio Health Group HMO |
$2,289.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,442.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,656.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,106.57
|
| Rate for Payer: PHCS Commercial |
$2,930.88
|
| Rate for Payer: United Healthcare All Payer |
$2,686.64
|
|
|
INTMD RPR S/TR/EXT >30.0 CM
|
Facility
|
OP
|
$2,423.00
|
|
|
Service Code
|
HCPCS 12037
|
| Hospital Charge Code |
761T2582
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$833.27 |
| Max. Negotiated Rate |
$2,366.24 |
| Rate for Payer: Aetna Commercial |
$1,865.71
|
| Rate for Payer: Anthem Medicaid |
$833.27
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,690.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,889.94
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,366.24
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,281.73
|
| Rate for Payer: Cash Price |
$1,211.50
|
| Rate for Payer: Cash Price |
$1,211.50
|
| Rate for Payer: Cigna Commercial |
$2,011.09
|
| Rate for Payer: First Health Commercial |
$2,301.85
|
| Rate for Payer: Humana Commercial |
$2,059.55
|
| Rate for Payer: Humana KY Medicaid |
$833.27
|
| Rate for Payer: Humana Medicare Advantage |
$1,690.17
|
| Rate for Payer: Kentucky WC Medicaid |
$841.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,986.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,788.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,028.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$849.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,132.24
|
| Rate for Payer: Ohio Health Group HMO |
$1,817.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,938.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,108.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,671.87
|
| Rate for Payer: PHCS Commercial |
$2,326.08
|
| Rate for Payer: United Healthcare All Payer |
$2,132.24
|
|
|
INTMD RPR S/TR/EXT >30.0 CM
|
Professional
|
Both
|
$3,053.00
|
|
|
Service Code
|
HCPCS 12037
|
| Hospital Charge Code |
76102582
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$167.50 |
| Max. Negotiated Rate |
$1,831.80 |
| Rate for Payer: Aetna Commercial |
$464.33
|
| Rate for Payer: Ambetter Exchange |
$309.93
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$167.50
|
| Rate for Payer: Anthem Medicaid |
$230.11
|
| Rate for Payer: Buckeye Individual/Medicaid |
$309.93
|
| Rate for Payer: Buckeye Medicare Advantage |
$309.93
|
| Rate for Payer: CareSource Just4Me Medicare |
$371.92
|
| Rate for Payer: Cash Price |
$1,526.50
|
| Rate for Payer: Cash Price |
$1,526.50
|
| Rate for Payer: Cigna Commercial |
$444.78
|
| Rate for Payer: Healthspan PPO |
$507.37
|
| Rate for Payer: Humana Medicaid |
$230.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$392.10
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$309.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$309.93
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$234.71
|
| Rate for Payer: Molina Healthcare Passport |
$230.11
|
| Rate for Payer: Multiplan PHCS |
$1,831.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$402.91
|
| Rate for Payer: UHCCP Medicaid |
$175.88
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$232.41
|
| Rate for Payer: Wellcare Medicare Advantage |
$309.93
|
|
|
INTMD RPR S/TR/EXT >30.0 CM
|
Facility
|
OP
|
$3,053.00
|
|
|
Service Code
|
HCPCS 12037
|
| Hospital Charge Code |
76102582
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,049.93 |
| Max. Negotiated Rate |
$2,930.88 |
| Rate for Payer: Aetna Commercial |
$2,350.81
|
| Rate for Payer: Anthem Medicaid |
$1,049.93
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,690.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,381.34
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,366.24
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,281.73
|
| Rate for Payer: Cash Price |
$1,526.50
|
| Rate for Payer: Cash Price |
$1,526.50
|
| Rate for Payer: Cigna Commercial |
$2,533.99
|
| Rate for Payer: First Health Commercial |
$2,900.35
|
| Rate for Payer: Humana Commercial |
$2,595.05
|
| Rate for Payer: Humana KY Medicaid |
$1,049.93
|
| Rate for Payer: Humana Medicare Advantage |
$1,690.17
|
| Rate for Payer: Kentucky WC Medicaid |
$1,060.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,503.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,253.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,028.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,070.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,686.64
|
| Rate for Payer: Ohio Health Group HMO |
$2,289.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,442.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,656.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,106.57
|
| Rate for Payer: PHCS Commercial |
$2,930.88
|
| Rate for Payer: United Healthcare All Payer |
$2,686.64
|
|
|
INTMD RPR S/TR/EXT >30.0 CM
|
Professional
|
Both
|
$630.00
|
|
|
Service Code
|
HCPCS 12037
|
| Hospital Charge Code |
761P2582
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$167.50 |
| Max. Negotiated Rate |
$507.37 |
| Rate for Payer: Aetna Commercial |
$464.33
|
| Rate for Payer: Ambetter Exchange |
$309.93
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$167.50
|
| Rate for Payer: Anthem Medicaid |
$230.11
|
| Rate for Payer: Buckeye Individual/Medicaid |
$309.93
|
| Rate for Payer: Buckeye Medicare Advantage |
$309.93
|
| Rate for Payer: CareSource Just4Me Medicare |
$371.92
|
| Rate for Payer: Cash Price |
$315.00
|
| Rate for Payer: Cash Price |
$315.00
|
| Rate for Payer: Cigna Commercial |
$444.78
|
| Rate for Payer: Healthspan PPO |
$507.37
|
| Rate for Payer: Humana Medicaid |
$230.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$392.10
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$309.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$309.93
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$234.71
|
| Rate for Payer: Molina Healthcare Passport |
$230.11
|
| Rate for Payer: Multiplan PHCS |
$378.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$402.91
|
| Rate for Payer: UHCCP Medicaid |
$175.88
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$232.41
|
| Rate for Payer: Wellcare Medicare Advantage |
$309.93
|
|
|
INTMD RPR S/TR/EXT >30.0 CM
|
Facility
|
IP
|
$2,423.00
|
|
|
Service Code
|
HCPCS 12037
|
| Hospital Charge Code |
761T2582
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$726.90 |
| Max. Negotiated Rate |
$2,326.08 |
| Rate for Payer: Aetna Commercial |
$1,865.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,889.94
|
| Rate for Payer: Cash Price |
$1,211.50
|
| Rate for Payer: Cigna Commercial |
$2,011.09
|
| Rate for Payer: First Health Commercial |
$2,301.85
|
| Rate for Payer: Humana Commercial |
$2,059.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,986.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,788.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$726.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,132.24
|
| Rate for Payer: Ohio Health Group HMO |
$1,817.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,938.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,108.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,671.87
|
| Rate for Payer: PHCS Commercial |
$2,326.08
|
| Rate for Payer: United Healthcare All Payer |
$2,132.24
|
|
|
INTMD WND REPAIR FACE/MM
|
Facility
|
IP
|
$2,299.17
|
|
|
Service Code
|
HCPCS 12056
|
| Hospital Charge Code |
76100148
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$689.75 |
| Max. Negotiated Rate |
$2,207.20 |
| Rate for Payer: Aetna Commercial |
$1,770.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,793.35
|
| Rate for Payer: Cash Price |
$1,149.59
|
| Rate for Payer: Cigna Commercial |
$1,908.31
|
| Rate for Payer: First Health Commercial |
$2,184.21
|
| Rate for Payer: Humana Commercial |
$1,954.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,885.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,696.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$689.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,023.27
|
| Rate for Payer: Ohio Health Group HMO |
$1,724.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,839.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,000.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,586.43
|
| Rate for Payer: PHCS Commercial |
$2,207.20
|
| Rate for Payer: United Healthcare All Payer |
$2,023.27
|
|
|
INTMD WND REPAIR FACE/MM
|
Professional
|
Both
|
$2,299.17
|
|
|
Service Code
|
HCPCS 12056
|
| Hospital Charge Code |
76100148
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$195.87 |
| Max. Negotiated Rate |
$1,379.50 |
| Rate for Payer: Aetna Commercial |
$492.27
|
| Rate for Payer: Ambetter Exchange |
$362.13
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$195.87
|
| Rate for Payer: Anthem Medicaid |
$292.06
|
| Rate for Payer: Buckeye Individual/Medicaid |
$362.13
|
| Rate for Payer: Buckeye Medicare Advantage |
$362.13
|
| Rate for Payer: CareSource Just4Me Medicare |
$434.56
|
| Rate for Payer: Cash Price |
$1,149.59
|
| Rate for Payer: Cash Price |
$1,149.59
|
| Rate for Payer: Cigna Commercial |
$471.46
|
| Rate for Payer: Healthspan PPO |
$555.80
|
| Rate for Payer: Humana Medicaid |
$292.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$426.67
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$362.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$362.13
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$297.90
|
| Rate for Payer: Molina Healthcare Passport |
$292.06
|
| Rate for Payer: Multiplan PHCS |
$1,379.50
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$470.77
|
| Rate for Payer: UHCCP Medicaid |
$205.66
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$294.98
|
| Rate for Payer: Wellcare Medicare Advantage |
$362.13
|
|
|
INTMD WND REPAIR FACE/MM
|
Facility
|
OP
|
$2,299.17
|
|
|
Service Code
|
HCPCS 12056
|
| Hospital Charge Code |
76100148
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$369.16 |
| Max. Negotiated Rate |
$2,207.20 |
| Rate for Payer: Aetna Commercial |
$1,770.36
|
| Rate for Payer: Anthem Medicaid |
$790.68
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$369.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,793.35
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$516.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$498.37
|
| Rate for Payer: Cash Price |
$1,149.59
|
| Rate for Payer: Cash Price |
$1,149.59
|
| Rate for Payer: Cigna Commercial |
$1,908.31
|
| Rate for Payer: First Health Commercial |
$2,184.21
|
| Rate for Payer: Humana Commercial |
$1,954.29
|
| Rate for Payer: Humana KY Medicaid |
$790.68
|
| Rate for Payer: Humana Medicare Advantage |
$369.16
|
| Rate for Payer: Kentucky WC Medicaid |
$798.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,885.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,696.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$442.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$806.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,023.27
|
| Rate for Payer: Ohio Health Group HMO |
$1,724.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,839.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,000.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,586.43
|
| Rate for Payer: PHCS Commercial |
$2,207.20
|
| Rate for Payer: United Healthcare All Payer |
$2,023.27
|
|
|
INTMD WND REPAIR FACE/MM(P
|
Professional
|
Both
|
$1,100.00
|
|
|
Service Code
|
HCPCS 12056
|
| Hospital Charge Code |
761P0148
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$195.87 |
| Max. Negotiated Rate |
$660.00 |
| Rate for Payer: Aetna Commercial |
$492.27
|
| Rate for Payer: Ambetter Exchange |
$362.13
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$195.87
|
| Rate for Payer: Anthem Medicaid |
$292.06
|
| Rate for Payer: Buckeye Individual/Medicaid |
$362.13
|
| Rate for Payer: Buckeye Medicare Advantage |
$362.13
|
| Rate for Payer: CareSource Just4Me Medicare |
$434.56
|
| Rate for Payer: Cash Price |
$550.00
|
| Rate for Payer: Cash Price |
$550.00
|
| Rate for Payer: Cigna Commercial |
$471.46
|
| Rate for Payer: Healthspan PPO |
$555.80
|
| Rate for Payer: Humana Medicaid |
$292.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$426.67
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$362.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$362.13
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$297.90
|
| Rate for Payer: Molina Healthcare Passport |
$292.06
|
| Rate for Payer: Multiplan PHCS |
$660.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$470.77
|
| Rate for Payer: UHCCP Medicaid |
$205.66
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$294.98
|
| Rate for Payer: Wellcare Medicare Advantage |
$362.13
|
|
|
INTMD WND REPAIR FACE/MM(T
|
Facility
|
IP
|
$1,199.17
|
|
|
Service Code
|
HCPCS 12056
|
| Hospital Charge Code |
761T0148
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$359.75 |
| Max. Negotiated Rate |
$1,151.20 |
| Rate for Payer: Aetna Commercial |
$923.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$935.35
|
| Rate for Payer: Cash Price |
$599.58
|
| Rate for Payer: Cigna Commercial |
$995.31
|
| Rate for Payer: First Health Commercial |
$1,139.21
|
| Rate for Payer: Humana Commercial |
$1,019.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$983.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$884.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$359.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,055.27
|
| Rate for Payer: Ohio Health Group HMO |
$899.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$959.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,043.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$827.43
|
| Rate for Payer: PHCS Commercial |
$1,151.20
|
| Rate for Payer: United Healthcare All Payer |
$1,055.27
|
|
|
INTMD WND REPAIR FACE/MM(T
|
Facility
|
OP
|
$1,199.17
|
|
|
Service Code
|
HCPCS 12056
|
| Hospital Charge Code |
761T0148
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$369.16 |
| Max. Negotiated Rate |
$1,151.20 |
| Rate for Payer: Aetna Commercial |
$923.36
|
| Rate for Payer: Anthem Medicaid |
$412.39
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$369.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$935.35
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$516.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$498.37
|
| Rate for Payer: Cash Price |
$599.58
|
| Rate for Payer: Cash Price |
$599.58
|
| Rate for Payer: Cigna Commercial |
$995.31
|
| Rate for Payer: First Health Commercial |
$1,139.21
|
| Rate for Payer: Humana Commercial |
$1,019.29
|
| Rate for Payer: Humana KY Medicaid |
$412.39
|
| Rate for Payer: Humana Medicare Advantage |
$369.16
|
| Rate for Payer: Kentucky WC Medicaid |
$416.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$983.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$884.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$442.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$420.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,055.27
|
| Rate for Payer: Ohio Health Group HMO |
$899.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$959.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,043.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$827.43
|
| Rate for Payer: PHCS Commercial |
$1,151.20
|
| Rate for Payer: United Healthcare All Payer |
$1,055.27
|
|
