|
N BLOCK INJ BRACHIAL PLEXUS(P
|
Professional
|
Both
|
$250.00
|
|
|
Service Code
|
HCPCS 64415
|
| Hospital Charge Code |
761P2312
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$31.84 |
| Max. Negotiated Rate |
$156.45 |
| Rate for Payer: Aetna Commercial |
$119.44
|
| Rate for Payer: Ambetter Exchange |
$66.12
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$31.84
|
| Rate for Payer: Anthem Medicaid |
$87.79
|
| Rate for Payer: Buckeye Individual/Medicaid |
$66.12
|
| Rate for Payer: Buckeye Medicare Advantage |
$66.12
|
| Rate for Payer: CareSource Just4Me Medicare |
$79.34
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cigna Commercial |
$112.01
|
| Rate for Payer: Healthspan PPO |
$156.45
|
| Rate for Payer: Humana Medicaid |
$87.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$86.29
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$66.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$66.12
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$89.55
|
| Rate for Payer: Molina Healthcare Passport |
$87.79
|
| Rate for Payer: Multiplan PHCS |
$150.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$85.96
|
| Rate for Payer: UHCCP Medicaid |
$33.43
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$88.67
|
| Rate for Payer: Wellcare Medicare Advantage |
$66.12
|
|
|
N BLOCK INJ BRACHIAL PLEXUS(T
|
Facility
|
IP
|
$2,220.77
|
|
|
Service Code
|
HCPCS 64415
|
| Hospital Charge Code |
761T2312
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$666.23 |
| Max. Negotiated Rate |
$2,131.94 |
| Rate for Payer: Aetna Commercial |
$1,709.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,732.20
|
| Rate for Payer: Cash Price |
$1,110.38
|
| Rate for Payer: Cigna Commercial |
$1,843.24
|
| Rate for Payer: First Health Commercial |
$2,109.73
|
| Rate for Payer: Humana Commercial |
$1,887.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,821.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,638.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$666.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,954.28
|
| Rate for Payer: Ohio Health Group HMO |
$1,665.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,776.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,932.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,532.33
|
| Rate for Payer: PHCS Commercial |
$2,131.94
|
| Rate for Payer: United Healthcare All Payer |
$1,954.28
|
|
|
N BLOCK INJ BRACHIAL PLEXUS(T
|
Facility
|
OP
|
$2,220.77
|
|
|
Service Code
|
HCPCS 64415
|
| Hospital Charge Code |
761T2312
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$763.72 |
| Max. Negotiated Rate |
$2,131.94 |
| Rate for Payer: Aetna Commercial |
$1,709.99
|
| Rate for Payer: Anthem Medicaid |
$763.72
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$822.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,732.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,151.65
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,110.52
|
| Rate for Payer: Cash Price |
$1,110.38
|
| Rate for Payer: Cash Price |
$1,110.38
|
| Rate for Payer: Cigna Commercial |
$1,843.24
|
| Rate for Payer: First Health Commercial |
$2,109.73
|
| Rate for Payer: Humana Commercial |
$1,887.65
|
| Rate for Payer: Humana KY Medicaid |
$763.72
|
| Rate for Payer: Humana Medicare Advantage |
$822.61
|
| Rate for Payer: Kentucky WC Medicaid |
$771.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,821.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,638.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$987.13
|
| Rate for Payer: Molina Healthcare Medicaid |
$779.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,954.28
|
| Rate for Payer: Ohio Health Group HMO |
$1,665.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,776.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,932.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,532.33
|
| Rate for Payer: PHCS Commercial |
$2,131.94
|
| Rate for Payer: United Healthcare All Payer |
$1,954.28
|
|
|
N BLOCK INJ CELIAC PELUS
|
Professional
|
Both
|
$225.00
|
|
|
Service Code
|
HCPCS 64530
|
| Hospital Charge Code |
76102974
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$47.76 |
| Max. Negotiated Rate |
$226.46 |
| Rate for Payer: Aetna Commercial |
$144.36
|
| Rate for Payer: Ambetter Exchange |
$88.87
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$47.76
|
| Rate for Payer: Anthem Medicaid |
$84.55
|
| Rate for Payer: Buckeye Individual/Medicaid |
$88.87
|
| Rate for Payer: Buckeye Medicare Advantage |
$88.87
|
| Rate for Payer: CareSource Just4Me Medicare |
$106.64
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cigna Commercial |
$129.64
|
| Rate for Payer: Healthspan PPO |
$226.46
|
| Rate for Payer: Humana Medicaid |
$84.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$115.15
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$88.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$88.87
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$86.24
|
| Rate for Payer: Molina Healthcare Passport |
$84.55
|
| Rate for Payer: Multiplan PHCS |
$135.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$115.53
|
| Rate for Payer: UHCCP Medicaid |
$50.15
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$85.40
|
| Rate for Payer: Wellcare Medicare Advantage |
$88.87
|
|
|
N BLOCK INJ COMMON DIGIT
|
Professional
|
Both
|
$195.00
|
|
|
Service Code
|
HCPCS 64632
|
| Hospital Charge Code |
76102650
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$46.50 |
| Max. Negotiated Rate |
$131.55 |
| Rate for Payer: Aetna Commercial |
$115.09
|
| Rate for Payer: Ambetter Exchange |
$64.05
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$46.50
|
| Rate for Payer: Anthem Medicaid |
$65.27
|
| Rate for Payer: Buckeye Individual/Medicaid |
$64.05
|
| Rate for Payer: Buckeye Medicare Advantage |
$64.05
|
| Rate for Payer: CareSource Just4Me Medicare |
$76.86
|
| Rate for Payer: Cash Price |
$97.50
|
| Rate for Payer: Cash Price |
$97.50
|
| Rate for Payer: Cigna Commercial |
$131.55
|
| Rate for Payer: Healthspan PPO |
$104.30
|
| Rate for Payer: Humana Medicaid |
$65.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$89.50
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$64.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$64.05
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$66.58
|
| Rate for Payer: Molina Healthcare Passport |
$65.27
|
| Rate for Payer: Multiplan PHCS |
$117.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$83.27
|
| Rate for Payer: UHCCP Medicaid |
$48.83
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$65.92
|
| Rate for Payer: Wellcare Medicare Advantage |
$64.05
|
|
|
N BLOCK INJ HYPOGAS PLXS
|
Facility
|
IP
|
$2,454.00
|
|
|
Service Code
|
HCPCS 64517
|
| Hospital Charge Code |
76102334
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$736.20 |
| Max. Negotiated Rate |
$2,355.84 |
| Rate for Payer: Aetna Commercial |
$1,889.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,914.12
|
| Rate for Payer: Cash Price |
$1,227.00
|
| Rate for Payer: Cigna Commercial |
$2,036.82
|
| Rate for Payer: First Health Commercial |
$2,331.30
|
| Rate for Payer: Humana Commercial |
$2,085.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,012.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,811.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$736.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,159.52
|
| Rate for Payer: Ohio Health Group HMO |
$1,840.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,963.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,134.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,693.26
|
| Rate for Payer: PHCS Commercial |
$2,355.84
|
| Rate for Payer: United Healthcare All Payer |
$2,159.52
|
|
|
N BLOCK INJ HYPOGAS PLXS
|
Facility
|
OP
|
$2,454.00
|
|
|
Service Code
|
HCPCS 64517
|
| Hospital Charge Code |
76102334
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$822.61 |
| Max. Negotiated Rate |
$2,355.84 |
| Rate for Payer: Aetna Commercial |
$1,889.58
|
| Rate for Payer: Anthem Medicaid |
$843.93
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$822.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,914.12
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,151.65
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,110.52
|
| Rate for Payer: Cash Price |
$1,227.00
|
| Rate for Payer: Cash Price |
$1,227.00
|
| Rate for Payer: Cigna Commercial |
$2,036.82
|
| Rate for Payer: First Health Commercial |
$2,331.30
|
| Rate for Payer: Humana Commercial |
$2,085.90
|
| Rate for Payer: Humana KY Medicaid |
$843.93
|
| Rate for Payer: Humana Medicare Advantage |
$822.61
|
| Rate for Payer: Kentucky WC Medicaid |
$852.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,012.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,811.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$987.13
|
| Rate for Payer: Molina Healthcare Medicaid |
$860.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,159.52
|
| Rate for Payer: Ohio Health Group HMO |
$1,840.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,963.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,134.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,693.26
|
| Rate for Payer: PHCS Commercial |
$2,355.84
|
| Rate for Payer: United Healthcare All Payer |
$2,159.52
|
|
|
N BLOCK INJ HYPOGAS PLXS
|
Professional
|
Both
|
$2,454.00
|
|
|
Service Code
|
HCPCS 64517
|
| Hospital Charge Code |
76102334
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$64.02 |
| Max. Negotiated Rate |
$1,472.40 |
| Rate for Payer: Aetna Commercial |
$189.57
|
| Rate for Payer: Ambetter Exchange |
$119.10
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$64.02
|
| Rate for Payer: Anthem Medicaid |
$137.32
|
| Rate for Payer: Buckeye Individual/Medicaid |
$119.10
|
| Rate for Payer: Buckeye Medicare Advantage |
$119.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$142.92
|
| Rate for Payer: Cash Price |
$1,227.00
|
| Rate for Payer: Cash Price |
$1,227.00
|
| Rate for Payer: Cigna Commercial |
$175.10
|
| Rate for Payer: Healthspan PPO |
$204.44
|
| Rate for Payer: Humana Medicaid |
$137.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$152.50
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$119.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$119.10
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$140.07
|
| Rate for Payer: Molina Healthcare Passport |
$137.32
|
| Rate for Payer: Multiplan PHCS |
$1,472.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$154.83
|
| Rate for Payer: UHCCP Medicaid |
$67.22
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$138.69
|
| Rate for Payer: Wellcare Medicare Advantage |
$119.10
|
|
|
N BLOCK INJ HYPOGAS PLXS(P
|
Professional
|
Both
|
$550.00
|
|
|
Service Code
|
HCPCS 64517
|
| Hospital Charge Code |
761P2334
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$64.02 |
| Max. Negotiated Rate |
$330.00 |
| Rate for Payer: Aetna Commercial |
$189.57
|
| Rate for Payer: Ambetter Exchange |
$119.10
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$64.02
|
| Rate for Payer: Anthem Medicaid |
$137.32
|
| Rate for Payer: Buckeye Individual/Medicaid |
$119.10
|
| Rate for Payer: Buckeye Medicare Advantage |
$119.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$142.92
|
| Rate for Payer: Cash Price |
$275.00
|
| Rate for Payer: Cash Price |
$275.00
|
| Rate for Payer: Cigna Commercial |
$175.10
|
| Rate for Payer: Healthspan PPO |
$204.44
|
| Rate for Payer: Humana Medicaid |
$137.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$152.50
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$119.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$119.10
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$140.07
|
| Rate for Payer: Molina Healthcare Passport |
$137.32
|
| Rate for Payer: Multiplan PHCS |
$330.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$154.83
|
| Rate for Payer: UHCCP Medicaid |
$67.22
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$138.69
|
| Rate for Payer: Wellcare Medicare Advantage |
$119.10
|
|
|
N BLOCK INJ HYPOGAS PLXS(T
|
Facility
|
IP
|
$1,904.00
|
|
|
Service Code
|
HCPCS 64517
|
| Hospital Charge Code |
761T2334
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$571.20 |
| Max. Negotiated Rate |
$1,827.84 |
| Rate for Payer: Aetna Commercial |
$1,466.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,485.12
|
| Rate for Payer: Cash Price |
$952.00
|
| Rate for Payer: Cigna Commercial |
$1,580.32
|
| Rate for Payer: First Health Commercial |
$1,808.80
|
| Rate for Payer: Humana Commercial |
$1,618.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,561.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,405.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$571.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,675.52
|
| Rate for Payer: Ohio Health Group HMO |
$1,428.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,523.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,656.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,313.76
|
| Rate for Payer: PHCS Commercial |
$1,827.84
|
| Rate for Payer: United Healthcare All Payer |
$1,675.52
|
|
|
N BLOCK INJ HYPOGAS PLXS(T
|
Facility
|
OP
|
$1,904.00
|
|
|
Service Code
|
HCPCS 64517
|
| Hospital Charge Code |
761T2334
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$654.79 |
| Max. Negotiated Rate |
$1,827.84 |
| Rate for Payer: Aetna Commercial |
$1,466.08
|
| Rate for Payer: Anthem Medicaid |
$654.79
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$822.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,485.12
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,151.65
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,110.52
|
| Rate for Payer: Cash Price |
$952.00
|
| Rate for Payer: Cash Price |
$952.00
|
| Rate for Payer: Cigna Commercial |
$1,580.32
|
| Rate for Payer: First Health Commercial |
$1,808.80
|
| Rate for Payer: Humana Commercial |
$1,618.40
|
| Rate for Payer: Humana KY Medicaid |
$654.79
|
| Rate for Payer: Humana Medicare Advantage |
$822.61
|
| Rate for Payer: Kentucky WC Medicaid |
$661.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,561.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,405.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$987.13
|
| Rate for Payer: Molina Healthcare Medicaid |
$667.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,675.52
|
| Rate for Payer: Ohio Health Group HMO |
$1,428.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,523.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,656.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,313.76
|
| Rate for Payer: PHCS Commercial |
$1,827.84
|
| Rate for Payer: United Healthcare All Payer |
$1,675.52
|
|
|
N BLOCK INJ PLANTAR DIGIT
|
Facility
|
IP
|
$488.00
|
|
|
Service Code
|
HCPCS 64455
|
| Hospital Charge Code |
36001278
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$146.40 |
| Max. Negotiated Rate |
$468.48 |
| Rate for Payer: Aetna Commercial |
$375.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$380.64
|
| Rate for Payer: Cash Price |
$244.00
|
| Rate for Payer: Cigna Commercial |
$405.04
|
| Rate for Payer: First Health Commercial |
$463.60
|
| Rate for Payer: Humana Commercial |
$414.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$400.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$360.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$146.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$429.44
|
| Rate for Payer: Ohio Health Group HMO |
$366.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$390.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$424.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$336.72
|
| Rate for Payer: PHCS Commercial |
$468.48
|
| Rate for Payer: United Healthcare All Payer |
$429.44
|
|
|
N BLOCK INJ PLANTAR DIGIT
|
Professional
|
Both
|
$610.00
|
|
|
Service Code
|
HCPCS 64455
|
| Hospital Charge Code |
76102320
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$25.87 |
| Max. Negotiated Rate |
$366.00 |
| Rate for Payer: Aetna Commercial |
$67.55
|
| Rate for Payer: Ambetter Exchange |
$31.53
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$25.87
|
| Rate for Payer: Anthem Medicaid |
$32.04
|
| Rate for Payer: Buckeye Individual/Medicaid |
$31.53
|
| Rate for Payer: Buckeye Medicare Advantage |
$31.53
|
| Rate for Payer: CareSource Just4Me Medicare |
$37.84
|
| Rate for Payer: Cash Price |
$305.00
|
| Rate for Payer: Cash Price |
$305.00
|
| Rate for Payer: Cigna Commercial |
$81.44
|
| Rate for Payer: Healthspan PPO |
$65.38
|
| Rate for Payer: Humana Medicaid |
$32.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$47.61
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$31.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$31.53
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$32.68
|
| Rate for Payer: Molina Healthcare Passport |
$32.04
|
| Rate for Payer: Multiplan PHCS |
$366.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$40.99
|
| Rate for Payer: UHCCP Medicaid |
$27.16
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$32.36
|
| Rate for Payer: Wellcare Medicare Advantage |
$31.53
|
|
|
N BLOCK INJ PLANTAR DIGIT
|
Professional
|
Both
|
$488.00
|
|
|
Service Code
|
HCPCS 64455
|
| Hospital Charge Code |
36001278
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$25.87 |
| Max. Negotiated Rate |
$292.80 |
| Rate for Payer: Aetna Commercial |
$67.55
|
| Rate for Payer: Ambetter Exchange |
$31.53
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$25.87
|
| Rate for Payer: Anthem Medicaid |
$32.04
|
| Rate for Payer: Buckeye Individual/Medicaid |
$31.53
|
| Rate for Payer: Buckeye Medicare Advantage |
$31.53
|
| Rate for Payer: CareSource Just4Me Medicare |
$37.84
|
| Rate for Payer: Cash Price |
$244.00
|
| Rate for Payer: Cash Price |
$244.00
|
| Rate for Payer: Cigna Commercial |
$81.44
|
| Rate for Payer: Healthspan PPO |
$65.38
|
| Rate for Payer: Humana Medicaid |
$32.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$47.61
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$31.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$31.53
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$32.68
|
| Rate for Payer: Molina Healthcare Passport |
$32.04
|
| Rate for Payer: Multiplan PHCS |
$292.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$40.99
|
| Rate for Payer: UHCCP Medicaid |
$27.16
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$32.36
|
| Rate for Payer: Wellcare Medicare Advantage |
$31.53
|
|
|
N BLOCK INJ PLANTAR DIGIT
|
Facility
|
OP
|
$488.00
|
|
|
Service Code
|
HCPCS 64455
|
| Hospital Charge Code |
36001278
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$167.82 |
| Max. Negotiated Rate |
$468.48 |
| Rate for Payer: Aetna Commercial |
$375.76
|
| Rate for Payer: Anthem Medicaid |
$167.82
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$272.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$380.64
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$381.85
|
| Rate for Payer: CareSource Just4Me Medicare |
$368.21
|
| Rate for Payer: Cash Price |
$244.00
|
| Rate for Payer: Cash Price |
$244.00
|
| Rate for Payer: Cigna Commercial |
$405.04
|
| Rate for Payer: First Health Commercial |
$463.60
|
| Rate for Payer: Humana Commercial |
$414.80
|
| Rate for Payer: Humana KY Medicaid |
$167.82
|
| Rate for Payer: Humana Medicare Advantage |
$272.75
|
| Rate for Payer: Kentucky WC Medicaid |
$169.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$400.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$360.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$327.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$171.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$429.44
|
| Rate for Payer: Ohio Health Group HMO |
$366.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$390.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$424.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$336.72
|
| Rate for Payer: PHCS Commercial |
$468.48
|
| Rate for Payer: United Healthcare All Payer |
$429.44
|
|
|
N BLOCK INJ PLANTAR DIGIT
|
Professional
|
Both
|
$488.00
|
|
|
Service Code
|
HCPCS 64455
|
| Hospital Charge Code |
360P1278
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$25.87 |
| Max. Negotiated Rate |
$292.80 |
| Rate for Payer: Aetna Commercial |
$67.55
|
| Rate for Payer: Ambetter Exchange |
$31.53
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$25.87
|
| Rate for Payer: Anthem Medicaid |
$32.04
|
| Rate for Payer: Buckeye Individual/Medicaid |
$31.53
|
| Rate for Payer: Buckeye Medicare Advantage |
$31.53
|
| Rate for Payer: CareSource Just4Me Medicare |
$37.84
|
| Rate for Payer: Cash Price |
$244.00
|
| Rate for Payer: Cash Price |
$244.00
|
| Rate for Payer: Cigna Commercial |
$81.44
|
| Rate for Payer: Healthspan PPO |
$65.38
|
| Rate for Payer: Humana Medicaid |
$32.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$47.61
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$31.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$31.53
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$32.68
|
| Rate for Payer: Molina Healthcare Passport |
$32.04
|
| Rate for Payer: Multiplan PHCS |
$292.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$40.99
|
| Rate for Payer: UHCCP Medicaid |
$27.16
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$32.36
|
| Rate for Payer: Wellcare Medicare Advantage |
$31.53
|
|
|
N BLOCK INJ PLANTAR DIGIT
|
Facility
|
IP
|
$610.00
|
|
|
Service Code
|
HCPCS 64455
|
| Hospital Charge Code |
76102320
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$183.00 |
| Max. Negotiated Rate |
$585.60 |
| Rate for Payer: Aetna Commercial |
$469.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$475.80
|
| Rate for Payer: Cash Price |
$305.00
|
| Rate for Payer: Cigna Commercial |
$506.30
|
| Rate for Payer: First Health Commercial |
$579.50
|
| Rate for Payer: Humana Commercial |
$518.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$500.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$450.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$183.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$536.80
|
| Rate for Payer: Ohio Health Group HMO |
$457.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$488.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$530.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$420.90
|
| Rate for Payer: PHCS Commercial |
$585.60
|
| Rate for Payer: United Healthcare All Payer |
$536.80
|
|
|
N BLOCK INJ PLANTAR DIGIT
|
Facility
|
OP
|
$610.00
|
|
|
Service Code
|
HCPCS 64455
|
| Hospital Charge Code |
76102320
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$209.78 |
| Max. Negotiated Rate |
$585.60 |
| Rate for Payer: Aetna Commercial |
$469.70
|
| Rate for Payer: Anthem Medicaid |
$209.78
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$272.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$475.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$381.85
|
| Rate for Payer: CareSource Just4Me Medicare |
$368.21
|
| Rate for Payer: Cash Price |
$305.00
|
| Rate for Payer: Cash Price |
$305.00
|
| Rate for Payer: Cigna Commercial |
$506.30
|
| Rate for Payer: First Health Commercial |
$579.50
|
| Rate for Payer: Humana Commercial |
$518.50
|
| Rate for Payer: Humana KY Medicaid |
$209.78
|
| Rate for Payer: Humana Medicare Advantage |
$272.75
|
| Rate for Payer: Kentucky WC Medicaid |
$211.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$500.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$450.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$327.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$213.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$536.80
|
| Rate for Payer: Ohio Health Group HMO |
$457.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$488.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$530.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$420.90
|
| Rate for Payer: PHCS Commercial |
$585.60
|
| Rate for Payer: United Healthcare All Payer |
$536.80
|
|
|
N BLOCK INJ PLANTAR DIGIT(P
|
Professional
|
Both
|
$235.00
|
|
|
Service Code
|
HCPCS 64455
|
| Hospital Charge Code |
761P2320
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$25.87 |
| Max. Negotiated Rate |
$141.00 |
| Rate for Payer: Aetna Commercial |
$67.55
|
| Rate for Payer: Ambetter Exchange |
$31.53
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$25.87
|
| Rate for Payer: Anthem Medicaid |
$32.04
|
| Rate for Payer: Buckeye Individual/Medicaid |
$31.53
|
| Rate for Payer: Buckeye Medicare Advantage |
$31.53
|
| Rate for Payer: CareSource Just4Me Medicare |
$37.84
|
| Rate for Payer: Cash Price |
$117.50
|
| Rate for Payer: Cash Price |
$117.50
|
| Rate for Payer: Cigna Commercial |
$81.44
|
| Rate for Payer: Healthspan PPO |
$65.38
|
| Rate for Payer: Humana Medicaid |
$32.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$47.61
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$31.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$31.53
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$32.68
|
| Rate for Payer: Molina Healthcare Passport |
$32.04
|
| Rate for Payer: Multiplan PHCS |
$141.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$40.99
|
| Rate for Payer: UHCCP Medicaid |
$27.16
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$32.36
|
| Rate for Payer: Wellcare Medicare Advantage |
$31.53
|
|
|
N BLOCK INJ PLANTAR DIGIT(T
|
Facility
|
IP
|
$375.00
|
|
|
Service Code
|
HCPCS 64455
|
| Hospital Charge Code |
761T2320
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$112.50 |
| Max. Negotiated Rate |
$360.00 |
| Rate for Payer: Aetna Commercial |
$288.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$292.50
|
| Rate for Payer: Cash Price |
$187.50
|
| Rate for Payer: Cigna Commercial |
$311.25
|
| Rate for Payer: First Health Commercial |
$356.25
|
| Rate for Payer: Humana Commercial |
$318.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$307.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$276.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$112.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$330.00
|
| Rate for Payer: Ohio Health Group HMO |
$281.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$300.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$326.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$258.75
|
| Rate for Payer: PHCS Commercial |
$360.00
|
| Rate for Payer: United Healthcare All Payer |
$330.00
|
|
|
N BLOCK INJ PLANTAR DIGIT(T
|
Facility
|
OP
|
$375.00
|
|
|
Service Code
|
HCPCS 64455
|
| Hospital Charge Code |
761T2320
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$128.96 |
| Max. Negotiated Rate |
$381.85 |
| Rate for Payer: Aetna Commercial |
$288.75
|
| Rate for Payer: Anthem Medicaid |
$128.96
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$272.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$292.50
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$381.85
|
| Rate for Payer: CareSource Just4Me Medicare |
$368.21
|
| Rate for Payer: Cash Price |
$187.50
|
| Rate for Payer: Cash Price |
$187.50
|
| Rate for Payer: Cigna Commercial |
$311.25
|
| Rate for Payer: First Health Commercial |
$356.25
|
| Rate for Payer: Humana Commercial |
$318.75
|
| Rate for Payer: Humana KY Medicaid |
$128.96
|
| Rate for Payer: Humana Medicare Advantage |
$272.75
|
| Rate for Payer: Kentucky WC Medicaid |
$130.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$307.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$276.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$327.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$131.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$330.00
|
| Rate for Payer: Ohio Health Group HMO |
$281.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$300.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$326.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$258.75
|
| Rate for Payer: PHCS Commercial |
$360.00
|
| Rate for Payer: United Healthcare All Payer |
$330.00
|
|
|
N BLOCK INJ SCIATIC SNG
|
Facility
|
OP
|
$2,295.77
|
|
|
Service Code
|
HCPCS 64445
|
| Hospital Charge Code |
76102317
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$639.87 |
| Max. Negotiated Rate |
$2,203.94 |
| Rate for Payer: Aetna Commercial |
$1,767.74
|
| Rate for Payer: Anthem Medicaid |
$789.52
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$639.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,790.70
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$895.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$863.82
|
| Rate for Payer: Cash Price |
$1,147.88
|
| Rate for Payer: Cash Price |
$1,147.88
|
| Rate for Payer: Cigna Commercial |
$1,905.49
|
| Rate for Payer: First Health Commercial |
$2,180.98
|
| Rate for Payer: Humana Commercial |
$1,951.40
|
| Rate for Payer: Humana KY Medicaid |
$789.52
|
| Rate for Payer: Humana Medicare Advantage |
$639.87
|
| Rate for Payer: Kentucky WC Medicaid |
$797.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,882.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,694.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$767.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$805.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,020.28
|
| Rate for Payer: Ohio Health Group HMO |
$1,721.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,836.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,997.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,584.08
|
| Rate for Payer: PHCS Commercial |
$2,203.94
|
| Rate for Payer: United Healthcare All Payer |
$2,020.28
|
|
|
N BLOCK INJ SCIATIC SNG
|
Professional
|
Both
|
$2,295.77
|
|
|
Service Code
|
HCPCS 64445
|
| Hospital Charge Code |
76102317
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$30.35 |
| Max. Negotiated Rate |
$1,377.46 |
| Rate for Payer: Aetna Commercial |
$129.45
|
| Rate for Payer: Ambetter Exchange |
$68.28
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$30.35
|
| Rate for Payer: Anthem Medicaid |
$95.75
|
| Rate for Payer: Buckeye Individual/Medicaid |
$68.28
|
| Rate for Payer: Buckeye Medicare Advantage |
$68.28
|
| Rate for Payer: CareSource Just4Me Medicare |
$81.94
|
| Rate for Payer: Cash Price |
$1,147.88
|
| Rate for Payer: Cash Price |
$1,147.88
|
| Rate for Payer: Cigna Commercial |
$227.10
|
| Rate for Payer: Healthspan PPO |
$162.46
|
| Rate for Payer: Humana Medicaid |
$95.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$96.87
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$68.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$68.28
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$97.67
|
| Rate for Payer: Molina Healthcare Passport |
$95.75
|
| Rate for Payer: Multiplan PHCS |
$1,377.46
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$88.76
|
| Rate for Payer: UHCCP Medicaid |
$31.87
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$96.71
|
| Rate for Payer: Wellcare Medicare Advantage |
$68.28
|
|
|
N BLOCK INJ SCIATIC SNG
|
Facility
|
IP
|
$2,295.77
|
|
|
Service Code
|
HCPCS 64445
|
| Hospital Charge Code |
76102317
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$688.73 |
| Max. Negotiated Rate |
$2,203.94 |
| Rate for Payer: Aetna Commercial |
$1,767.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,790.70
|
| Rate for Payer: Cash Price |
$1,147.88
|
| Rate for Payer: Cigna Commercial |
$1,905.49
|
| Rate for Payer: First Health Commercial |
$2,180.98
|
| Rate for Payer: Humana Commercial |
$1,951.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,882.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,694.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$688.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,020.28
|
| Rate for Payer: Ohio Health Group HMO |
$1,721.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,836.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,997.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,584.08
|
| Rate for Payer: PHCS Commercial |
$2,203.94
|
| Rate for Payer: United Healthcare All Payer |
$2,020.28
|
|
|
N BLOCK INJ SCIATIC SNG(P
|
Professional
|
Both
|
$500.00
|
|
|
Service Code
|
HCPCS 64445
|
| Hospital Charge Code |
761P2317
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$30.35 |
| Max. Negotiated Rate |
$300.00 |
| Rate for Payer: Aetna Commercial |
$129.45
|
| Rate for Payer: Ambetter Exchange |
$68.28
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$30.35
|
| Rate for Payer: Anthem Medicaid |
$95.75
|
| Rate for Payer: Buckeye Individual/Medicaid |
$68.28
|
| Rate for Payer: Buckeye Medicare Advantage |
$68.28
|
| Rate for Payer: CareSource Just4Me Medicare |
$81.94
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Cigna Commercial |
$227.10
|
| Rate for Payer: Healthspan PPO |
$162.46
|
| Rate for Payer: Humana Medicaid |
$95.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$96.87
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$68.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$68.28
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$97.67
|
| Rate for Payer: Molina Healthcare Passport |
$95.75
|
| Rate for Payer: Multiplan PHCS |
$300.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$88.76
|
| Rate for Payer: UHCCP Medicaid |
$31.87
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$96.71
|
| Rate for Payer: Wellcare Medicare Advantage |
$68.28
|
|
