|
CLTX RAD&ULN SHAFT FX W/O MAN
|
Professional
|
Both
|
$1,589.00
|
|
|
Service Code
|
HCPCS 25560
|
| Hospital Charge Code |
76100626
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$134.64 |
| Max. Negotiated Rate |
$953.40 |
| Rate for Payer: Aetna Commercial |
$319.64
|
| Rate for Payer: Ambetter Exchange |
$252.87
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$136.84
|
| Rate for Payer: Anthem Medicaid |
$134.64
|
| Rate for Payer: Buckeye Individual/Medicaid |
$252.87
|
| Rate for Payer: Buckeye Medicare Advantage |
$252.87
|
| Rate for Payer: CareSource Just4Me Medicare |
$303.44
|
| Rate for Payer: Cash Price |
$794.50
|
| Rate for Payer: Cash Price |
$794.50
|
| Rate for Payer: Cigna Commercial |
$397.61
|
| Rate for Payer: Healthspan PPO |
$321.03
|
| Rate for Payer: Humana Medicaid |
$134.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$288.86
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$252.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$252.87
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$137.33
|
| Rate for Payer: Molina Healthcare Passport |
$134.64
|
| Rate for Payer: Multiplan PHCS |
$953.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$328.73
|
| Rate for Payer: UHCCP Medicaid |
$143.68
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$135.99
|
| Rate for Payer: Wellcare Medicare Advantage |
$252.87
|
|
|
CLTX RAD&ULN SHAFT FX W/O MAN
|
Facility
|
IP
|
$1,589.00
|
|
|
Service Code
|
HCPCS 25560
|
| Hospital Charge Code |
76100626
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$476.70 |
| Max. Negotiated Rate |
$1,525.44 |
| Rate for Payer: Aetna Commercial |
$1,223.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,239.42
|
| Rate for Payer: Cash Price |
$794.50
|
| Rate for Payer: Cigna Commercial |
$1,318.87
|
| Rate for Payer: First Health Commercial |
$1,509.55
|
| Rate for Payer: Humana Commercial |
$1,350.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,302.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,172.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$476.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,398.32
|
| Rate for Payer: Ohio Health Group HMO |
$1,191.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,271.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,382.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,096.41
|
| Rate for Payer: PHCS Commercial |
$1,525.44
|
| Rate for Payer: United Healthcare All Payer |
$1,398.32
|
|
|
CLTX RAD&ULN SHAFT FX W/O MA(P
|
Professional
|
Both
|
$630.00
|
|
|
Service Code
|
HCPCS 25560
|
| Hospital Charge Code |
761P0626
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$134.64 |
| Max. Negotiated Rate |
$397.61 |
| Rate for Payer: Aetna Commercial |
$319.64
|
| Rate for Payer: Ambetter Exchange |
$252.87
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$136.84
|
| Rate for Payer: Anthem Medicaid |
$134.64
|
| Rate for Payer: Buckeye Individual/Medicaid |
$252.87
|
| Rate for Payer: Buckeye Medicare Advantage |
$252.87
|
| Rate for Payer: CareSource Just4Me Medicare |
$303.44
|
| Rate for Payer: Cash Price |
$315.00
|
| Rate for Payer: Cash Price |
$315.00
|
| Rate for Payer: Cigna Commercial |
$397.61
|
| Rate for Payer: Healthspan PPO |
$321.03
|
| Rate for Payer: Humana Medicaid |
$134.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$288.86
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$252.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$252.87
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$137.33
|
| Rate for Payer: Molina Healthcare Passport |
$134.64
|
| Rate for Payer: Multiplan PHCS |
$378.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$328.73
|
| Rate for Payer: UHCCP Medicaid |
$143.68
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$135.99
|
| Rate for Payer: Wellcare Medicare Advantage |
$252.87
|
|
|
CLTX RAD&ULN SHAFT FX W/O MA(T
|
Facility
|
OP
|
$959.00
|
|
|
Service Code
|
HCPCS 25560
|
| Hospital Charge Code |
761T0626
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$221.64 |
| Max. Negotiated Rate |
$920.64 |
| Rate for Payer: Aetna Commercial |
$738.43
|
| Rate for Payer: Anthem Medicaid |
$329.80
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$221.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$748.02
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$310.30
|
| Rate for Payer: CareSource Just4Me Medicare |
$299.21
|
| Rate for Payer: Cash Price |
$479.50
|
| Rate for Payer: Cash Price |
$479.50
|
| Rate for Payer: Cigna Commercial |
$795.97
|
| Rate for Payer: First Health Commercial |
$911.05
|
| Rate for Payer: Humana Commercial |
$815.15
|
| Rate for Payer: Humana KY Medicaid |
$329.80
|
| Rate for Payer: Humana Medicare Advantage |
$221.64
|
| Rate for Payer: Kentucky WC Medicaid |
$333.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$786.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$707.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$265.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$336.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$843.92
|
| Rate for Payer: Ohio Health Group HMO |
$719.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$767.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$834.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$661.71
|
| Rate for Payer: PHCS Commercial |
$920.64
|
| Rate for Payer: United Healthcare All Payer |
$843.92
|
|
|
CLTX RAD&ULN SHAFT FX W/O MA(T
|
Facility
|
IP
|
$959.00
|
|
|
Service Code
|
HCPCS 25560
|
| Hospital Charge Code |
761T0626
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$287.70 |
| Max. Negotiated Rate |
$920.64 |
| Rate for Payer: Aetna Commercial |
$738.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$748.02
|
| Rate for Payer: Cash Price |
$479.50
|
| Rate for Payer: Cigna Commercial |
$795.97
|
| Rate for Payer: First Health Commercial |
$911.05
|
| Rate for Payer: Humana Commercial |
$815.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$786.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$707.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$287.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$843.92
|
| Rate for Payer: Ohio Health Group HMO |
$719.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$767.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$834.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$661.71
|
| Rate for Payer: PHCS Commercial |
$920.64
|
| Rate for Payer: United Healthcare All Payer |
$843.92
|
|
|
CLTX RDLSHF FX DIS DIST R/U JT
|
Facility
|
IP
|
$3,277.00
|
|
|
Service Code
|
HCPCS 25520
|
| Hospital Charge Code |
76100620
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$983.10 |
| Max. Negotiated Rate |
$3,145.92 |
| Rate for Payer: Aetna Commercial |
$2,523.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,556.06
|
| Rate for Payer: Cash Price |
$1,638.50
|
| Rate for Payer: Cigna Commercial |
$2,719.91
|
| Rate for Payer: First Health Commercial |
$3,113.15
|
| Rate for Payer: Humana Commercial |
$2,785.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,687.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,418.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$983.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,883.76
|
| Rate for Payer: Ohio Health Group HMO |
$2,457.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,621.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,850.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,261.13
|
| Rate for Payer: PHCS Commercial |
$3,145.92
|
| Rate for Payer: United Healthcare All Payer |
$2,883.76
|
|
|
CLTX RDLSHF FX DIS DIST R/U JT
|
Professional
|
Both
|
$1,280.00
|
|
|
Service Code
|
HCPCS 25520
|
| Hospital Charge Code |
761P0620
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$353.15 |
| Max. Negotiated Rate |
$864.80 |
| Rate for Payer: Aetna Commercial |
$737.27
|
| Rate for Payer: Ambetter Exchange |
$525.54
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$353.92
|
| Rate for Payer: Anthem Medicaid |
$353.15
|
| Rate for Payer: Buckeye Individual/Medicaid |
$525.54
|
| Rate for Payer: Buckeye Medicare Advantage |
$525.54
|
| Rate for Payer: CareSource Just4Me Medicare |
$630.65
|
| Rate for Payer: Cash Price |
$640.00
|
| Rate for Payer: Cash Price |
$640.00
|
| Rate for Payer: Cigna Commercial |
$864.80
|
| Rate for Payer: Healthspan PPO |
$697.39
|
| Rate for Payer: Humana Medicaid |
$353.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$643.46
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$525.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$525.54
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$360.21
|
| Rate for Payer: Molina Healthcare Passport |
$353.15
|
| Rate for Payer: Multiplan PHCS |
$768.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$683.20
|
| Rate for Payer: UHCCP Medicaid |
$371.62
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$356.68
|
| Rate for Payer: Wellcare Medicare Advantage |
$525.54
|
|
|
CLTX RDLSHF FX DIS DIST R/U JT
|
Facility
|
OP
|
$1,997.00
|
|
|
Service Code
|
HCPCS 25520
|
| Hospital Charge Code |
761T0620
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$686.77 |
| Max. Negotiated Rate |
$2,070.25 |
| Rate for Payer: Aetna Commercial |
$1,537.69
|
| Rate for Payer: Anthem Medicaid |
$686.77
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,478.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,557.66
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,070.25
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,996.31
|
| Rate for Payer: Cash Price |
$998.50
|
| Rate for Payer: Cash Price |
$998.50
|
| Rate for Payer: Cigna Commercial |
$1,657.51
|
| Rate for Payer: First Health Commercial |
$1,897.15
|
| Rate for Payer: Humana Commercial |
$1,697.45
|
| Rate for Payer: Humana KY Medicaid |
$686.77
|
| Rate for Payer: Humana Medicare Advantage |
$1,478.75
|
| Rate for Payer: Kentucky WC Medicaid |
$693.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,637.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,473.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,774.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$700.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,757.36
|
| Rate for Payer: Ohio Health Group HMO |
$1,497.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,597.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,737.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,377.93
|
| Rate for Payer: PHCS Commercial |
$1,917.12
|
| Rate for Payer: United Healthcare All Payer |
$1,757.36
|
|
|
CLTX RDLSHF FX DIS DIST R/U JT
|
Professional
|
Both
|
$3,277.00
|
|
|
Service Code
|
HCPCS 25520
|
| Hospital Charge Code |
76100620
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$353.15 |
| Max. Negotiated Rate |
$1,966.20 |
| Rate for Payer: Aetna Commercial |
$737.27
|
| Rate for Payer: Ambetter Exchange |
$525.54
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$353.92
|
| Rate for Payer: Anthem Medicaid |
$353.15
|
| Rate for Payer: Buckeye Individual/Medicaid |
$525.54
|
| Rate for Payer: Buckeye Medicare Advantage |
$525.54
|
| Rate for Payer: CareSource Just4Me Medicare |
$630.65
|
| Rate for Payer: Cash Price |
$1,638.50
|
| Rate for Payer: Cash Price |
$1,638.50
|
| Rate for Payer: Cigna Commercial |
$864.80
|
| Rate for Payer: Healthspan PPO |
$697.39
|
| Rate for Payer: Humana Medicaid |
$353.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$643.46
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$525.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$525.54
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$360.21
|
| Rate for Payer: Molina Healthcare Passport |
$353.15
|
| Rate for Payer: Multiplan PHCS |
$1,966.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$683.20
|
| Rate for Payer: UHCCP Medicaid |
$371.62
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$356.68
|
| Rate for Payer: Wellcare Medicare Advantage |
$525.54
|
|
|
CLTX RDLSHF FX DIS DIST R/U JT
|
Facility
|
OP
|
$3,277.00
|
|
|
Service Code
|
HCPCS 25520
|
| Hospital Charge Code |
76100620
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,126.96 |
| Max. Negotiated Rate |
$3,145.92 |
| Rate for Payer: Aetna Commercial |
$2,523.29
|
| Rate for Payer: Anthem Medicaid |
$1,126.96
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,478.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,556.06
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,070.25
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,996.31
|
| Rate for Payer: Cash Price |
$1,638.50
|
| Rate for Payer: Cash Price |
$1,638.50
|
| Rate for Payer: Cigna Commercial |
$2,719.91
|
| Rate for Payer: First Health Commercial |
$3,113.15
|
| Rate for Payer: Humana Commercial |
$2,785.45
|
| Rate for Payer: Humana KY Medicaid |
$1,126.96
|
| Rate for Payer: Humana Medicare Advantage |
$1,478.75
|
| Rate for Payer: Kentucky WC Medicaid |
$1,138.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,687.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,418.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,774.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,149.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,883.76
|
| Rate for Payer: Ohio Health Group HMO |
$2,457.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,621.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,850.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,261.13
|
| Rate for Payer: PHCS Commercial |
$3,145.92
|
| Rate for Payer: United Healthcare All Payer |
$2,883.76
|
|
|
CLTX RDLSHF FX DIS DIST R/U JT
|
Facility
|
IP
|
$1,997.00
|
|
|
Service Code
|
HCPCS 25520
|
| Hospital Charge Code |
761T0620
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$599.10 |
| Max. Negotiated Rate |
$1,917.12 |
| Rate for Payer: Aetna Commercial |
$1,537.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,557.66
|
| Rate for Payer: Cash Price |
$998.50
|
| Rate for Payer: Cigna Commercial |
$1,657.51
|
| Rate for Payer: First Health Commercial |
$1,897.15
|
| Rate for Payer: Humana Commercial |
$1,697.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,637.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,473.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$599.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,757.36
|
| Rate for Payer: Ohio Health Group HMO |
$1,497.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,597.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,737.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,377.93
|
| Rate for Payer: PHCS Commercial |
$1,917.12
|
| Rate for Payer: United Healthcare All Payer |
$1,757.36
|
|
|
CLTX SHLDR DISLC WFX HUM TUBRT
|
Facility
|
IP
|
$3,031.00
|
|
|
Service Code
|
HCPCS 23665
|
| Hospital Charge Code |
76100488
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$909.30 |
| Max. Negotiated Rate |
$2,909.76 |
| Rate for Payer: Aetna Commercial |
$2,333.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,364.18
|
| Rate for Payer: Cash Price |
$1,515.50
|
| Rate for Payer: Cigna Commercial |
$2,515.73
|
| Rate for Payer: First Health Commercial |
$2,879.45
|
| Rate for Payer: Humana Commercial |
$2,576.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,485.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,236.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$909.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,667.28
|
| Rate for Payer: Ohio Health Group HMO |
$2,273.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,424.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,636.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,091.39
|
| Rate for Payer: PHCS Commercial |
$2,909.76
|
| Rate for Payer: United Healthcare All Payer |
$2,667.28
|
|
|
CLTX SHLDR DISLC WFX HUM TUBRT
|
Professional
|
Both
|
$3,031.00
|
|
|
Service Code
|
HCPCS 23665
|
| Hospital Charge Code |
76100488
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$224.31 |
| Max. Negotiated Rate |
$1,818.60 |
| Rate for Payer: Aetna Commercial |
$549.19
|
| Rate for Payer: Ambetter Exchange |
$387.28
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$227.75
|
| Rate for Payer: Anthem Medicaid |
$224.31
|
| Rate for Payer: Buckeye Individual/Medicaid |
$387.28
|
| Rate for Payer: Buckeye Medicare Advantage |
$387.28
|
| Rate for Payer: CareSource Just4Me Medicare |
$464.74
|
| Rate for Payer: Cash Price |
$1,515.50
|
| Rate for Payer: Cash Price |
$1,515.50
|
| Rate for Payer: Cigna Commercial |
$642.55
|
| Rate for Payer: Healthspan PPO |
$525.57
|
| Rate for Payer: Humana Medicaid |
$224.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$476.53
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$387.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$387.28
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$228.80
|
| Rate for Payer: Molina Healthcare Passport |
$224.31
|
| Rate for Payer: Multiplan PHCS |
$1,818.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$503.46
|
| Rate for Payer: UHCCP Medicaid |
$239.14
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$226.55
|
| Rate for Payer: Wellcare Medicare Advantage |
$387.28
|
|
|
CLTX SHLDR DISLC WFX HUM TUBRT
|
Facility
|
OP
|
$3,031.00
|
|
|
Service Code
|
HCPCS 23665
|
| Hospital Charge Code |
76100488
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,042.36 |
| Max. Negotiated Rate |
$2,909.76 |
| Rate for Payer: Aetna Commercial |
$2,333.87
|
| Rate for Payer: Anthem Medicaid |
$1,042.36
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,478.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,364.18
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,070.25
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,996.31
|
| Rate for Payer: Cash Price |
$1,515.50
|
| Rate for Payer: Cash Price |
$1,515.50
|
| Rate for Payer: Cigna Commercial |
$2,515.73
|
| Rate for Payer: First Health Commercial |
$2,879.45
|
| Rate for Payer: Humana Commercial |
$2,576.35
|
| Rate for Payer: Humana KY Medicaid |
$1,042.36
|
| Rate for Payer: Humana Medicare Advantage |
$1,478.75
|
| Rate for Payer: Kentucky WC Medicaid |
$1,052.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,485.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,236.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,774.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,063.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,667.28
|
| Rate for Payer: Ohio Health Group HMO |
$2,273.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,424.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,636.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,091.39
|
| Rate for Payer: PHCS Commercial |
$2,909.76
|
| Rate for Payer: United Healthcare All Payer |
$2,667.28
|
|
|
CLTX SHLDR DISLC WFX HUM TUBRT
|
Facility
|
IP
|
$2,111.00
|
|
|
Service Code
|
HCPCS 23665
|
| Hospital Charge Code |
761T0488
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$633.30 |
| Max. Negotiated Rate |
$2,026.56 |
| Rate for Payer: Aetna Commercial |
$1,625.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,646.58
|
| Rate for Payer: Cash Price |
$1,055.50
|
| Rate for Payer: Cigna Commercial |
$1,752.13
|
| Rate for Payer: First Health Commercial |
$2,005.45
|
| Rate for Payer: Humana Commercial |
$1,794.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,731.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,557.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$633.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,857.68
|
| Rate for Payer: Ohio Health Group HMO |
$1,583.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,688.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,836.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,456.59
|
| Rate for Payer: PHCS Commercial |
$2,026.56
|
| Rate for Payer: United Healthcare All Payer |
$1,857.68
|
|
|
CLTX SHLDR DISLC WFX HUM TUBRT
|
Facility
|
IP
|
$2,111.00
|
|
|
Service Code
|
HCPCS 23665
|
| Hospital Charge Code |
45000114
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$633.30 |
| Max. Negotiated Rate |
$2,026.56 |
| Rate for Payer: Aetna Commercial |
$1,625.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,646.58
|
| Rate for Payer: Cash Price |
$1,055.50
|
| Rate for Payer: Cigna Commercial |
$1,752.13
|
| Rate for Payer: First Health Commercial |
$2,005.45
|
| Rate for Payer: Humana Commercial |
$1,794.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,731.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,557.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$633.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,857.68
|
| Rate for Payer: Ohio Health Group HMO |
$1,583.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,688.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,836.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,456.59
|
| Rate for Payer: PHCS Commercial |
$2,026.56
|
| Rate for Payer: United Healthcare All Payer |
$1,857.68
|
|
|
CLTX SHLDR DISLC WFX HUM TUBRT
|
Facility
|
OP
|
$2,111.00
|
|
|
Service Code
|
HCPCS 23665
|
| Hospital Charge Code |
45000114
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$725.97 |
| Max. Negotiated Rate |
$2,070.25 |
| Rate for Payer: Aetna Commercial |
$1,625.47
|
| Rate for Payer: Anthem Medicaid |
$725.97
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,478.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,646.58
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,070.25
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,996.31
|
| Rate for Payer: Cash Price |
$1,055.50
|
| Rate for Payer: Cash Price |
$1,055.50
|
| Rate for Payer: Cigna Commercial |
$1,752.13
|
| Rate for Payer: First Health Commercial |
$2,005.45
|
| Rate for Payer: Humana Commercial |
$1,794.35
|
| Rate for Payer: Humana KY Medicaid |
$725.97
|
| Rate for Payer: Humana Medicare Advantage |
$1,478.75
|
| Rate for Payer: Kentucky WC Medicaid |
$733.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,731.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,557.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,774.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$740.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,857.68
|
| Rate for Payer: Ohio Health Group HMO |
$1,583.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,688.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,836.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,456.59
|
| Rate for Payer: PHCS Commercial |
$2,026.56
|
| Rate for Payer: United Healthcare All Payer |
$1,857.68
|
|
|
CLTX SHLDR DISLC WFX HUM TUBRT
|
Professional
|
Both
|
$920.00
|
|
|
Service Code
|
HCPCS 23665
|
| Hospital Charge Code |
761P0488
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$224.31 |
| Max. Negotiated Rate |
$642.55 |
| Rate for Payer: Aetna Commercial |
$549.19
|
| Rate for Payer: Ambetter Exchange |
$387.28
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$227.75
|
| Rate for Payer: Anthem Medicaid |
$224.31
|
| Rate for Payer: Buckeye Individual/Medicaid |
$387.28
|
| Rate for Payer: Buckeye Medicare Advantage |
$387.28
|
| Rate for Payer: CareSource Just4Me Medicare |
$464.74
|
| Rate for Payer: Cash Price |
$460.00
|
| Rate for Payer: Cash Price |
$460.00
|
| Rate for Payer: Cigna Commercial |
$642.55
|
| Rate for Payer: Healthspan PPO |
$525.57
|
| Rate for Payer: Humana Medicaid |
$224.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$476.53
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$387.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$387.28
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$228.80
|
| Rate for Payer: Molina Healthcare Passport |
$224.31
|
| Rate for Payer: Multiplan PHCS |
$552.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$503.46
|
| Rate for Payer: UHCCP Medicaid |
$239.14
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$226.55
|
| Rate for Payer: Wellcare Medicare Advantage |
$387.28
|
|
|
CLTX SHLDR DISLC WFX HUM TUBRT
|
Facility
|
OP
|
$2,111.00
|
|
|
Service Code
|
HCPCS 23665
|
| Hospital Charge Code |
761T0488
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$725.97 |
| Max. Negotiated Rate |
$2,070.25 |
| Rate for Payer: Aetna Commercial |
$1,625.47
|
| Rate for Payer: Anthem Medicaid |
$725.97
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,478.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,646.58
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,070.25
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,996.31
|
| Rate for Payer: Cash Price |
$1,055.50
|
| Rate for Payer: Cash Price |
$1,055.50
|
| Rate for Payer: Cigna Commercial |
$1,752.13
|
| Rate for Payer: First Health Commercial |
$2,005.45
|
| Rate for Payer: Humana Commercial |
$1,794.35
|
| Rate for Payer: Humana KY Medicaid |
$725.97
|
| Rate for Payer: Humana Medicare Advantage |
$1,478.75
|
| Rate for Payer: Kentucky WC Medicaid |
$733.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,731.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,557.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,774.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$740.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,857.68
|
| Rate for Payer: Ohio Health Group HMO |
$1,583.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,688.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,836.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,456.59
|
| Rate for Payer: PHCS Commercial |
$2,026.56
|
| Rate for Payer: United Healthcare All Payer |
$1,857.68
|
|
|
CLTX SHLDR DIS W/ANTM NECKFX
|
Facility
|
OP
|
$2,111.00
|
|
|
Service Code
|
HCPCS 23675
|
| Hospital Charge Code |
45000115
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$725.97 |
| Max. Negotiated Rate |
$2,070.25 |
| Rate for Payer: Aetna Commercial |
$1,625.47
|
| Rate for Payer: Anthem Medicaid |
$725.97
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,478.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,646.58
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,070.25
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,996.31
|
| Rate for Payer: Cash Price |
$1,055.50
|
| Rate for Payer: Cash Price |
$1,055.50
|
| Rate for Payer: Cigna Commercial |
$1,752.13
|
| Rate for Payer: First Health Commercial |
$2,005.45
|
| Rate for Payer: Humana Commercial |
$1,794.35
|
| Rate for Payer: Humana KY Medicaid |
$725.97
|
| Rate for Payer: Humana Medicare Advantage |
$1,478.75
|
| Rate for Payer: Kentucky WC Medicaid |
$733.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,731.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,557.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,774.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$740.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,857.68
|
| Rate for Payer: Ohio Health Group HMO |
$1,583.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,688.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,836.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,456.59
|
| Rate for Payer: PHCS Commercial |
$2,026.56
|
| Rate for Payer: United Healthcare All Payer |
$1,857.68
|
|
|
CLTX SHLDR DIS W/ANTM NECKFX
|
Facility
|
IP
|
$3,551.00
|
|
|
Service Code
|
HCPCS 23675
|
| Hospital Charge Code |
76100490
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,065.30 |
| Max. Negotiated Rate |
$3,408.96 |
| Rate for Payer: Aetna Commercial |
$2,734.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,769.78
|
| Rate for Payer: Cash Price |
$1,775.50
|
| Rate for Payer: Cigna Commercial |
$2,947.33
|
| Rate for Payer: First Health Commercial |
$3,373.45
|
| Rate for Payer: Humana Commercial |
$3,018.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,911.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,620.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,065.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,124.88
|
| Rate for Payer: Ohio Health Group HMO |
$2,663.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,840.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,089.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,450.19
|
| Rate for Payer: PHCS Commercial |
$3,408.96
|
| Rate for Payer: United Healthcare All Payer |
$3,124.88
|
|
|
CLTX SHLDR DIS W/ANTM NECKFX
|
Professional
|
Both
|
$3,551.00
|
|
|
Service Code
|
HCPCS 23675
|
| Hospital Charge Code |
76100490
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$259.55 |
| Max. Negotiated Rate |
$2,130.60 |
| Rate for Payer: Aetna Commercial |
$710.49
|
| Rate for Payer: Ambetter Exchange |
$482.09
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$259.55
|
| Rate for Payer: Anthem Medicaid |
$284.56
|
| Rate for Payer: Buckeye Individual/Medicaid |
$482.09
|
| Rate for Payer: Buckeye Medicare Advantage |
$482.09
|
| Rate for Payer: CareSource Just4Me Medicare |
$578.51
|
| Rate for Payer: Cash Price |
$1,775.50
|
| Rate for Payer: Cash Price |
$1,775.50
|
| Rate for Payer: Cigna Commercial |
$847.61
|
| Rate for Payer: Healthspan PPO |
$690.10
|
| Rate for Payer: Humana Medicaid |
$284.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$609.98
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$482.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$482.09
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$290.25
|
| Rate for Payer: Molina Healthcare Passport |
$284.56
|
| Rate for Payer: Multiplan PHCS |
$2,130.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$626.72
|
| Rate for Payer: UHCCP Medicaid |
$272.53
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$287.41
|
| Rate for Payer: Wellcare Medicare Advantage |
$482.09
|
|
|
CLTX SHLDR DIS W/ANTM NECKFX
|
Facility
|
OP
|
$3,551.00
|
|
|
Service Code
|
HCPCS 23675
|
| Hospital Charge Code |
76100490
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,221.19 |
| Max. Negotiated Rate |
$3,408.96 |
| Rate for Payer: Aetna Commercial |
$2,734.27
|
| Rate for Payer: Anthem Medicaid |
$1,221.19
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,478.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,769.78
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,070.25
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,996.31
|
| Rate for Payer: Cash Price |
$1,775.50
|
| Rate for Payer: Cash Price |
$1,775.50
|
| Rate for Payer: Cigna Commercial |
$2,947.33
|
| Rate for Payer: First Health Commercial |
$3,373.45
|
| Rate for Payer: Humana Commercial |
$3,018.35
|
| Rate for Payer: Humana KY Medicaid |
$1,221.19
|
| Rate for Payer: Humana Medicare Advantage |
$1,478.75
|
| Rate for Payer: Kentucky WC Medicaid |
$1,233.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,911.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,620.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,774.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,245.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,124.88
|
| Rate for Payer: Ohio Health Group HMO |
$2,663.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,840.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,089.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,450.19
|
| Rate for Payer: PHCS Commercial |
$3,408.96
|
| Rate for Payer: United Healthcare All Payer |
$3,124.88
|
|
|
CLTX SHLDR DIS W/ANTM NECKFX
|
Facility
|
IP
|
$2,111.00
|
|
|
Service Code
|
HCPCS 23675
|
| Hospital Charge Code |
45000115
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$633.30 |
| Max. Negotiated Rate |
$2,026.56 |
| Rate for Payer: Aetna Commercial |
$1,625.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,646.58
|
| Rate for Payer: Cash Price |
$1,055.50
|
| Rate for Payer: Cigna Commercial |
$1,752.13
|
| Rate for Payer: First Health Commercial |
$2,005.45
|
| Rate for Payer: Humana Commercial |
$1,794.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,731.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,557.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$633.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,857.68
|
| Rate for Payer: Ohio Health Group HMO |
$1,583.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,688.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,836.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,456.59
|
| Rate for Payer: PHCS Commercial |
$2,026.56
|
| Rate for Payer: United Healthcare All Payer |
$1,857.68
|
|
|
CLTX SHLDR DIS W/ANTM NECKFX(P
|
Professional
|
Both
|
$1,440.00
|
|
|
Service Code
|
HCPCS 23675
|
| Hospital Charge Code |
761P0490
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$259.55 |
| Max. Negotiated Rate |
$864.00 |
| Rate for Payer: Aetna Commercial |
$710.49
|
| Rate for Payer: Ambetter Exchange |
$482.09
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$259.55
|
| Rate for Payer: Anthem Medicaid |
$284.56
|
| Rate for Payer: Buckeye Individual/Medicaid |
$482.09
|
| Rate for Payer: Buckeye Medicare Advantage |
$482.09
|
| Rate for Payer: CareSource Just4Me Medicare |
$578.51
|
| Rate for Payer: Cash Price |
$720.00
|
| Rate for Payer: Cash Price |
$720.00
|
| Rate for Payer: Cigna Commercial |
$847.61
|
| Rate for Payer: Healthspan PPO |
$690.10
|
| Rate for Payer: Humana Medicaid |
$284.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$609.98
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$482.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$482.09
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$290.25
|
| Rate for Payer: Molina Healthcare Passport |
$284.56
|
| Rate for Payer: Multiplan PHCS |
$864.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$626.72
|
| Rate for Payer: UHCCP Medicaid |
$272.53
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$287.41
|
| Rate for Payer: Wellcare Medicare Advantage |
$482.09
|
|
