Southern Ohio Medical Center

All Charges

Charge

Type

Setting

Price

MS-DRG 42.00: VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC

Facility

$11,518.35

Service Code	MSDRG 747
Min. Negotiated Rate	$7,816.02
Max. Negotiated Rate	$11,518.35
Rate for Payer: Anthem Medicaid	$7,816.02
Rate for Payer: Anthem Medicare Advantage/PPO	$8,227.39
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$11,518.35
Rate for Payer: CareSource Just4Me Medicare	$11,106.98
Rate for Payer: Humana KY Medicaid	$7,816.02
Rate for Payer: Humana Medicare Advantage	$8,227.39
Rate for Payer: Kentucky WC Medicaid	$7,894.18
Rate for Payer: Molina Healthcare Benefit Exchange	$9,872.87
Rate for Payer: Molina Healthcare Medicaid	$7,972.34

MS-DRG 42.00: VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C

Facility

$13,219.79

Service Code	MSDRG 768
Min. Negotiated Rate	$5,380.00
Max. Negotiated Rate	$13,219.79
Rate for Payer: Anthem Medicaid	$8,970.57
Rate for Payer: Anthem Medicare Advantage/PPO	$9,442.71
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$13,219.79
Rate for Payer: CareSource Just4Me Medicare	$12,747.66
Rate for Payer: Humana KY Medicaid	$8,970.57
Rate for Payer: Humana Medicare Advantage	$9,442.71
Rate for Payer: Kentucky WC Medicaid	$9,060.28
Rate for Payer: Molina Healthcare Benefit Exchange	$5,380.00
Rate for Payer: Molina Healthcare Medicaid	$9,149.99

MS-DRG 42.00: VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC

Facility

$8,725.57

Service Code	MSDRG 806
Min. Negotiated Rate	$5,380.00
Max. Negotiated Rate	$8,725.57
Rate for Payer: Anthem Medicaid	$5,920.92
Rate for Payer: Anthem Medicare Advantage/PPO	$6,232.55
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$8,725.57
Rate for Payer: CareSource Just4Me Medicare	$8,413.94
Rate for Payer: Humana KY Medicaid	$5,920.92
Rate for Payer: Humana Medicare Advantage	$6,232.55
Rate for Payer: Kentucky WC Medicaid	$5,980.13
Rate for Payer: Molina Healthcare Benefit Exchange	$5,380.00
Rate for Payer: Molina Healthcare Medicaid	$6,039.34

MS-DRG 42.00: VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC

Facility

$12,034.44

Service Code	MSDRG 805
Min. Negotiated Rate	$5,380.00
Max. Negotiated Rate	$12,034.44
Rate for Payer: Anthem Medicaid	$8,166.23
Rate for Payer: Anthem Medicare Advantage/PPO	$8,596.03
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$12,034.44
Rate for Payer: CareSource Just4Me Medicare	$11,604.64
Rate for Payer: Humana KY Medicaid	$8,166.23
Rate for Payer: Humana Medicare Advantage	$8,596.03
Rate for Payer: Kentucky WC Medicaid	$8,247.89
Rate for Payer: Molina Healthcare Benefit Exchange	$5,380.00
Rate for Payer: Molina Healthcare Medicaid	$8,329.55

MS-DRG 42.00: VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC

Facility

$7,684.92

Service Code	MSDRG 807
Min. Negotiated Rate	$5,214.77
Max. Negotiated Rate	$7,684.92
Rate for Payer: Anthem Medicaid	$5,214.77
Rate for Payer: Anthem Medicare Advantage/PPO	$5,489.23
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$7,684.92
Rate for Payer: CareSource Just4Me Medicare	$7,410.46
Rate for Payer: Humana KY Medicaid	$5,214.77
Rate for Payer: Humana Medicare Advantage	$5,489.23
Rate for Payer: Kentucky WC Medicaid	$5,266.92
Rate for Payer: Molina Healthcare Benefit Exchange	$5,380.00
Rate for Payer: Molina Healthcare Medicaid	$5,319.06

MS-DRG 42.00: VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC

Facility

$11,675.10

Service Code	MSDRG 797
Min. Negotiated Rate	$5,380.00
Max. Negotiated Rate	$11,675.10
Rate for Payer: Anthem Medicaid	$7,922.39
Rate for Payer: Anthem Medicare Advantage/PPO	$8,339.36
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$11,675.10
Rate for Payer: CareSource Just4Me Medicare	$11,258.14
Rate for Payer: Humana KY Medicaid	$7,922.39
Rate for Payer: Humana Medicare Advantage	$8,339.36
Rate for Payer: Kentucky WC Medicaid	$8,001.62
Rate for Payer: Molina Healthcare Benefit Exchange	$5,380.00
Rate for Payer: Molina Healthcare Medicaid	$8,080.84

MS-DRG 42.00: VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC

Facility

$15,393.95

Service Code	MSDRG 796
Min. Negotiated Rate	$5,380.00
Max. Negotiated Rate	$15,393.95
Rate for Payer: Anthem Medicaid	$10,445.90
Rate for Payer: Anthem Medicare Advantage/PPO	$10,995.68
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$15,393.95
Rate for Payer: CareSource Just4Me Medicare	$14,844.17
Rate for Payer: Humana KY Medicaid	$10,445.90
Rate for Payer: Humana Medicare Advantage	$10,995.68
Rate for Payer: Kentucky WC Medicaid	$10,550.35
Rate for Payer: Molina Healthcare Benefit Exchange	$5,380.00
Rate for Payer: Molina Healthcare Medicaid	$10,654.81

MS-DRG 42.00: VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC

Facility

$11,675.10

Service Code	MSDRG 798
Min. Negotiated Rate	$5,380.00
Max. Negotiated Rate	$11,675.10
Rate for Payer: Anthem Medicaid	$7,922.39
Rate for Payer: Anthem Medicare Advantage/PPO	$8,339.36
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$11,675.10
Rate for Payer: CareSource Just4Me Medicare	$11,258.14
Rate for Payer: Humana KY Medicaid	$7,922.39
Rate for Payer: Humana Medicare Advantage	$8,339.36
Rate for Payer: Kentucky WC Medicaid	$8,001.62
Rate for Payer: Molina Healthcare Benefit Exchange	$5,380.00
Rate for Payer: Molina Healthcare Medicaid	$8,080.84

MS-DRG 42.00: VEIN LIGATION AND STRIPPING

Facility

$32,342.28

Service Code	MSDRG 263
Min. Negotiated Rate	$21,946.55
Max. Negotiated Rate	$32,342.28
Rate for Payer: Anthem Medicaid	$21,946.55
Rate for Payer: Anthem Medicare Advantage/PPO	$23,101.63
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$32,342.28
Rate for Payer: CareSource Just4Me Medicare	$31,187.20
Rate for Payer: Humana KY Medicaid	$21,946.55
Rate for Payer: Humana Medicare Advantage	$23,101.63
Rate for Payer: Kentucky WC Medicaid	$22,166.01
Rate for Payer: Molina Healthcare Benefit Exchange	$27,721.96
Rate for Payer: Molina Healthcare Medicaid	$22,385.48

MS-DRG 42.00: VENTRICULAR SHUNT PROCEDURES WITH CC

Facility

$25,752.27

Service Code	MSDRG 032
Min. Negotiated Rate	$17,474.76
Max. Negotiated Rate	$25,752.27
Rate for Payer: Anthem Medicaid	$17,474.76
Rate for Payer: Anthem Medicare Advantage/PPO	$18,394.48
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$25,752.27
Rate for Payer: CareSource Just4Me Medicare	$24,832.55
Rate for Payer: Humana KY Medicaid	$17,474.76
Rate for Payer: Humana Medicare Advantage	$18,394.48
Rate for Payer: Kentucky WC Medicaid	$17,649.50
Rate for Payer: Molina Healthcare Benefit Exchange	$22,073.38
Rate for Payer: Molina Healthcare Medicaid	$17,824.25

MS-DRG 42.00: VENTRICULAR SHUNT PROCEDURES WITH MCC

Facility

$50,532.64

Service Code	MSDRG 031
Min. Negotiated Rate	$34,290.00
Max. Negotiated Rate	$50,532.64
Rate for Payer: Anthem Medicaid	$34,290.00
Rate for Payer: Anthem Medicare Advantage/PPO	$36,094.74
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$50,532.64
Rate for Payer: CareSource Just4Me Medicare	$48,727.90
Rate for Payer: Humana KY Medicaid	$34,290.00
Rate for Payer: Humana Medicare Advantage	$36,094.74
Rate for Payer: Kentucky WC Medicaid	$34,632.90
Rate for Payer: Molina Healthcare Benefit Exchange	$43,313.69
Rate for Payer: Molina Healthcare Medicaid	$34,975.80

MS-DRG 42.00: VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC

Facility

$19,239.46

Service Code	MSDRG 033
Min. Negotiated Rate	$13,055.35
Max. Negotiated Rate	$19,239.46
Rate for Payer: Anthem Medicaid	$13,055.35
Rate for Payer: Anthem Medicare Advantage/PPO	$13,742.47
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$19,239.46
Rate for Payer: CareSource Just4Me Medicare	$18,552.33
Rate for Payer: Humana KY Medicaid	$13,055.35
Rate for Payer: Humana Medicare Advantage	$13,742.47
Rate for Payer: Kentucky WC Medicaid	$13,185.90
Rate for Payer: Molina Healthcare Benefit Exchange	$16,490.96
Rate for Payer: Molina Healthcare Medicaid	$13,316.45

MS-DRG 42.00: VIRAL ILLNESS WITH MCC

Facility

$17,797.25

Service Code	MSDRG 865
Min. Negotiated Rate	$12,076.70
Max. Negotiated Rate	$17,797.25
Rate for Payer: Anthem Medicaid	$12,076.70
Rate for Payer: Anthem Medicare Advantage/PPO	$12,712.32
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$17,797.25
Rate for Payer: CareSource Just4Me Medicare	$17,161.63
Rate for Payer: Humana KY Medicaid	$12,076.70
Rate for Payer: Humana Medicare Advantage	$12,712.32
Rate for Payer: Kentucky WC Medicaid	$12,197.47
Rate for Payer: Molina Healthcare Benefit Exchange	$15,254.78
Rate for Payer: Molina Healthcare Medicaid	$12,318.24

MS-DRG 42.00: VIRAL ILLNESS WITHOUT MCC

Facility

$10,669.44

Service Code	MSDRG 866
Min. Negotiated Rate	$7,239.98
Max. Negotiated Rate	$10,669.44
Rate for Payer: Anthem Medicaid	$7,239.98
Rate for Payer: Anthem Medicare Advantage/PPO	$7,621.03
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$10,669.44
Rate for Payer: CareSource Just4Me Medicare	$10,288.39
Rate for Payer: Humana KY Medicaid	$7,239.98
Rate for Payer: Humana Medicare Advantage	$7,621.03
Rate for Payer: Kentucky WC Medicaid	$7,312.38
Rate for Payer: Molina Healthcare Benefit Exchange	$9,145.24
Rate for Payer: Molina Healthcare Medicaid	$7,384.78

MS-DRG 42.00: VIRAL MENINGITIS WITH CC/MCC

Facility

$20,769.69

Service Code	MSDRG 075
Min. Negotiated Rate	$14,093.72
Max. Negotiated Rate	$20,769.69
Rate for Payer: Anthem Medicaid	$14,093.72
Rate for Payer: Anthem Medicare Advantage/PPO	$14,835.49
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$20,769.69
Rate for Payer: CareSource Just4Me Medicare	$20,027.91
Rate for Payer: Humana KY Medicaid	$14,093.72
Rate for Payer: Humana Medicare Advantage	$14,835.49
Rate for Payer: Kentucky WC Medicaid	$14,234.65
Rate for Payer: Molina Healthcare Benefit Exchange	$17,802.59
Rate for Payer: Molina Healthcare Medicaid	$14,375.59

MS-DRG 42.00: VIRAL MENINGITIS WITHOUT CC/MCC

Facility

$11,056.49

Service Code	MSDRG 076
Min. Negotiated Rate	$7,502.62
Max. Negotiated Rate	$11,056.49
Rate for Payer: Anthem Medicaid	$7,502.62
Rate for Payer: Anthem Medicare Advantage/PPO	$7,897.49
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$11,056.49
Rate for Payer: CareSource Just4Me Medicare	$10,661.61
Rate for Payer: Humana KY Medicaid	$7,502.62
Rate for Payer: Humana Medicare Advantage	$7,897.49
Rate for Payer: Kentucky WC Medicaid	$7,577.64
Rate for Payer: Molina Healthcare Benefit Exchange	$9,476.99
Rate for Payer: Molina Healthcare Medicaid	$7,652.67

MS-DRG 42.00: WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC

Facility

$35,555.88

Service Code	MSDRG 464
Min. Negotiated Rate	$24,127.21
Max. Negotiated Rate	$35,555.88
Rate for Payer: Anthem Medicaid	$24,127.21
Rate for Payer: Anthem Medicare Advantage/PPO	$25,397.06
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$35,555.88
Rate for Payer: CareSource Just4Me Medicare	$34,286.03
Rate for Payer: Humana KY Medicaid	$24,127.21
Rate for Payer: Humana Medicare Advantage	$25,397.06
Rate for Payer: Kentucky WC Medicaid	$24,368.48
Rate for Payer: Molina Healthcare Benefit Exchange	$30,476.47
Rate for Payer: Molina Healthcare Medicaid	$24,609.75

MS-DRG 42.00: WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC

Facility

$65,128.32

Service Code	MSDRG 463
Min. Negotiated Rate	$44,194.22
Max. Negotiated Rate	$65,128.32
Rate for Payer: Anthem Medicaid	$44,194.22
Rate for Payer: Anthem Medicare Advantage/PPO	$46,520.23
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$65,128.32
Rate for Payer: CareSource Just4Me Medicare	$62,802.31
Rate for Payer: Humana KY Medicaid	$44,194.22
Rate for Payer: Humana Medicare Advantage	$46,520.23
Rate for Payer: Kentucky WC Medicaid	$44,636.16
Rate for Payer: Molina Healthcare Benefit Exchange	$55,824.28
Rate for Payer: Molina Healthcare Medicaid	$45,078.10

MS-DRG 42.00: WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC

Facility

$20,934.89

Service Code	MSDRG 465
Min. Negotiated Rate	$14,205.82
Max. Negotiated Rate	$20,934.89
Rate for Payer: Anthem Medicaid	$14,205.82
Rate for Payer: Anthem Medicare Advantage/PPO	$14,953.49
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$20,934.89
Rate for Payer: CareSource Just4Me Medicare	$20,187.21
Rate for Payer: Humana KY Medicaid	$14,205.82
Rate for Payer: Humana Medicare Advantage	$14,953.49
Rate for Payer: Kentucky WC Medicaid	$14,347.87
Rate for Payer: Molina Healthcare Benefit Exchange	$17,944.19
Rate for Payer: Molina Healthcare Medicaid	$14,489.93

MS-DRG 42.00: WOUND DEBRIDEMENTS FOR INJURIES WITH CC

Facility

$22,882.34

Service Code	MSDRG 902
Min. Negotiated Rate	$15,527.30
Max. Negotiated Rate	$22,882.34
Rate for Payer: Anthem Medicaid	$15,527.30
Rate for Payer: Anthem Medicare Advantage/PPO	$16,344.53
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$22,882.34
Rate for Payer: CareSource Just4Me Medicare	$22,065.12
Rate for Payer: Humana KY Medicaid	$15,527.30
Rate for Payer: Humana Medicare Advantage	$16,344.53
Rate for Payer: Kentucky WC Medicaid	$15,682.58
Rate for Payer: Molina Healthcare Benefit Exchange	$19,613.44
Rate for Payer: Molina Healthcare Medicaid	$15,837.85

MS-DRG 42.00: WOUND DEBRIDEMENTS FOR INJURIES WITH MCC

Facility

$53,425.48

Service Code	MSDRG 901
Min. Negotiated Rate	$36,253.01
Max. Negotiated Rate	$53,425.48
Rate for Payer: Anthem Medicaid	$36,253.01
Rate for Payer: Anthem Medicare Advantage/PPO	$38,161.06
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$53,425.48
Rate for Payer: CareSource Just4Me Medicare	$51,517.43
Rate for Payer: Humana KY Medicaid	$36,253.01
Rate for Payer: Humana Medicare Advantage	$38,161.06
Rate for Payer: Kentucky WC Medicaid	$36,615.54
Rate for Payer: Molina Healthcare Benefit Exchange	$45,793.27
Rate for Payer: Molina Healthcare Medicaid	$36,978.07

MS-DRG 42.00: WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC

Facility

$14,700.62

Service Code	MSDRG 903
Min. Negotiated Rate	$9,975.42
Max. Negotiated Rate	$14,700.62
Rate for Payer: Anthem Medicaid	$9,975.42
Rate for Payer: Anthem Medicare Advantage/PPO	$10,500.44
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$14,700.62
Rate for Payer: CareSource Just4Me Medicare	$14,175.59
Rate for Payer: Humana KY Medicaid	$9,975.42
Rate for Payer: Humana Medicare Advantage	$10,500.44
Rate for Payer: Kentucky WC Medicaid	$10,075.17
Rate for Payer: Molina Healthcare Benefit Exchange	$12,600.53
Rate for Payer: Molina Healthcare Medicaid	$10,174.93

M-SPEC FEM HEAD 36*1.5 12/14

Facility

$4,531.25

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,359.38
Max. Negotiated Rate	$4,350.00
Rate for Payer: Aetna Commercial	$3,489.06
Rate for Payer: Anthem POS/PPO/Traditional	$3,534.38
Rate for Payer: Cash Price	$2,265.62
Rate for Payer: Cigna Commercial	$3,760.94
Rate for Payer: First Health Commercial	$4,304.69
Rate for Payer: Humana Commercial	$3,851.56
Rate for Payer: Medical Mutual Of Ohio HMO	$3,715.62
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,344.06
Rate for Payer: Molina Healthcare Benefit Exchange	$1,359.38
Rate for Payer: Ohio Health Choice Commercial	$3,987.50
Rate for Payer: Ohio Health Group HMO	$3,398.44
Rate for Payer: Ohio Health Group PPO Differential	$3,625.00
Rate for Payer: Ohio Health Group PPO No Differential	$3,942.19
Rate for Payer: Ohio Health Group PPO SOMC Employees	$3,126.56
Rate for Payer: PHCS Commercial	$4,350.00
Rate for Payer: United Healthcare All Payer	$3,987.50

M-SPEC FEM HEAD 36*1.5 12/14

Facility

$4,531.25

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,359.38
Max. Negotiated Rate	$4,350.00
Rate for Payer: Aetna Commercial	$3,489.06
Rate for Payer: Anthem Medicaid	$1,558.30
Rate for Payer: Anthem POS/PPO/Traditional	$3,534.38
Rate for Payer: Cash Price	$2,265.62
Rate for Payer: Cigna Commercial	$3,760.94
Rate for Payer: First Health Commercial	$4,304.69
Rate for Payer: Humana Commercial	$3,851.56
Rate for Payer: Humana KY Medicaid	$1,558.30
Rate for Payer: Kentucky WC Medicaid	$1,574.16
Rate for Payer: Medical Mutual Of Ohio HMO	$3,715.62
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,344.06
Rate for Payer: Molina Healthcare Benefit Exchange	$1,359.38
Rate for Payer: Molina Healthcare Medicaid	$1,589.56
Rate for Payer: Ohio Health Choice Commercial	$3,987.50
Rate for Payer: Ohio Health Group HMO	$3,398.44
Rate for Payer: Ohio Health Group PPO Differential	$3,625.00
Rate for Payer: Ohio Health Group PPO No Differential	$3,942.19
Rate for Payer: Ohio Health Group PPO SOMC Employees	$3,126.56
Rate for Payer: PHCS Commercial	$4,350.00
Rate for Payer: United Healthcare All Payer	$3,987.50

M-SPEC FEMORAL HEAD 36MM-12/14

Facility

$4,531.25

Service Code	HCPCS C1776
Hospital Charge Code	27000011
Hospital Revenue Code	278
Min. Negotiated Rate	$1,359.38
Max. Negotiated Rate	$4,350.00
Rate for Payer: Aetna Commercial	$3,489.06
Rate for Payer: Anthem Medicaid	$1,558.30
Rate for Payer: Anthem POS/PPO/Traditional	$3,534.38
Rate for Payer: Cash Price	$2,265.62
Rate for Payer: Cigna Commercial	$3,760.94
Rate for Payer: First Health Commercial	$4,304.69
Rate for Payer: Humana Commercial	$3,851.56
Rate for Payer: Humana KY Medicaid	$1,558.30
Rate for Payer: Kentucky WC Medicaid	$1,574.16
Rate for Payer: Medical Mutual Of Ohio HMO	$3,715.62
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,344.06
Rate for Payer: Molina Healthcare Benefit Exchange	$1,359.38
Rate for Payer: Molina Healthcare Medicaid	$1,589.56
Rate for Payer: Ohio Health Choice Commercial	$3,987.50
Rate for Payer: Ohio Health Group HMO	$3,398.44
Rate for Payer: Ohio Health Group PPO Differential	$3,625.00
Rate for Payer: Ohio Health Group PPO No Differential	$3,942.19
Rate for Payer: Ohio Health Group PPO SOMC Employees	$3,126.56
Rate for Payer: PHCS Commercial	$4,350.00
Rate for Payer: United Healthcare All Payer	$3,987.50

Know your out-of-pocket cost for care.

All Charges