|
CYSTOSCOPY REMOVAL OF CLOTS
|
Professional
|
Both
|
$6,329.00
|
|
|
Service Code
|
HCPCS 52001
|
| Hospital Charge Code |
76102082
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$101.50 |
| Max. Negotiated Rate |
$3,797.40 |
| Rate for Payer: Aetna Commercial |
$477.76
|
| Rate for Payer: Ambetter Exchange |
$269.00
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$143.96
|
| Rate for Payer: Anthem Medicaid |
$101.50
|
| Rate for Payer: Buckeye Individual/Medicaid |
$269.00
|
| Rate for Payer: Buckeye Medicare Advantage |
$269.00
|
| Rate for Payer: CareSource Just4Me Medicare |
$322.80
|
| Rate for Payer: Cash Price |
$3,164.50
|
| Rate for Payer: Cash Price |
$3,164.50
|
| Rate for Payer: Cigna Commercial |
$424.41
|
| Rate for Payer: Healthspan PPO |
$494.57
|
| Rate for Payer: Humana Medicaid |
$101.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$393.53
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$269.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$269.00
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$103.53
|
| Rate for Payer: Molina Healthcare Passport |
$101.50
|
| Rate for Payer: Multiplan PHCS |
$3,797.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$349.70
|
| Rate for Payer: UHCCP Medicaid |
$151.16
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$102.52
|
| Rate for Payer: Wellcare Medicare Advantage |
$269.00
|
|
|
CYSTOSCOPY REMOVAL OF CLOTS
|
Facility
|
OP
|
$6,329.00
|
|
|
Service Code
|
HCPCS 52001
|
| Hospital Charge Code |
76102082
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,176.54 |
| Max. Negotiated Rate |
$6,075.84 |
| Rate for Payer: Aetna Commercial |
$4,873.33
|
| Rate for Payer: Anthem Medicaid |
$2,176.54
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,186.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,936.62
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,461.49
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,302.15
|
| Rate for Payer: Cash Price |
$3,164.50
|
| Rate for Payer: Cash Price |
$3,164.50
|
| Rate for Payer: Cigna Commercial |
$5,253.07
|
| Rate for Payer: First Health Commercial |
$6,012.55
|
| Rate for Payer: Humana Commercial |
$5,379.65
|
| Rate for Payer: Humana KY Medicaid |
$2,176.54
|
| Rate for Payer: Humana Medicare Advantage |
$3,186.78
|
| Rate for Payer: Kentucky WC Medicaid |
$2,198.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,189.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,670.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,824.14
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,220.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,569.52
|
| Rate for Payer: Ohio Health Group HMO |
$4,746.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,063.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,506.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,367.01
|
| Rate for Payer: PHCS Commercial |
$6,075.84
|
| Rate for Payer: United Healthcare All Payer |
$5,569.52
|
|
|
CYSTOSCOPY REMOVAL OF CLOTS
|
Facility
|
IP
|
$6,329.00
|
|
|
Service Code
|
HCPCS 52001
|
| Hospital Charge Code |
76102082
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,898.70 |
| Max. Negotiated Rate |
$6,075.84 |
| Rate for Payer: Aetna Commercial |
$4,873.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,936.62
|
| Rate for Payer: Cash Price |
$3,164.50
|
| Rate for Payer: Cigna Commercial |
$5,253.07
|
| Rate for Payer: First Health Commercial |
$6,012.55
|
| Rate for Payer: Humana Commercial |
$5,379.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,189.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,670.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,898.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,569.52
|
| Rate for Payer: Ohio Health Group HMO |
$4,746.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,063.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,506.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,367.01
|
| Rate for Payer: PHCS Commercial |
$6,075.84
|
| Rate for Payer: United Healthcare All Payer |
$5,569.52
|
|
|
CYSTOSCOPY REMOVAL OF CLOTS(P
|
Professional
|
Both
|
$800.00
|
|
|
Service Code
|
HCPCS 52001
|
| Hospital Charge Code |
761P2082
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$101.50 |
| Max. Negotiated Rate |
$494.57 |
| Rate for Payer: Aetna Commercial |
$477.76
|
| Rate for Payer: Ambetter Exchange |
$269.00
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$143.96
|
| Rate for Payer: Anthem Medicaid |
$101.50
|
| Rate for Payer: Buckeye Individual/Medicaid |
$269.00
|
| Rate for Payer: Buckeye Medicare Advantage |
$269.00
|
| Rate for Payer: CareSource Just4Me Medicare |
$322.80
|
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Cigna Commercial |
$424.41
|
| Rate for Payer: Healthspan PPO |
$494.57
|
| Rate for Payer: Humana Medicaid |
$101.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$393.53
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$269.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$269.00
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$103.53
|
| Rate for Payer: Molina Healthcare Passport |
$101.50
|
| Rate for Payer: Multiplan PHCS |
$480.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$349.70
|
| Rate for Payer: UHCCP Medicaid |
$151.16
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$102.52
|
| Rate for Payer: Wellcare Medicare Advantage |
$269.00
|
|
|
CYSTOSCOPY REMOVAL OF CLOTS(T
|
Facility
|
IP
|
$5,529.00
|
|
|
Service Code
|
HCPCS 52001
|
| Hospital Charge Code |
761T2082
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,658.70 |
| Max. Negotiated Rate |
$5,307.84 |
| Rate for Payer: Aetna Commercial |
$4,257.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,312.62
|
| Rate for Payer: Cash Price |
$2,764.50
|
| Rate for Payer: Cigna Commercial |
$4,589.07
|
| Rate for Payer: First Health Commercial |
$5,252.55
|
| Rate for Payer: Humana Commercial |
$4,699.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,533.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,080.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,658.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,865.52
|
| Rate for Payer: Ohio Health Group HMO |
$4,146.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,423.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,810.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,815.01
|
| Rate for Payer: PHCS Commercial |
$5,307.84
|
| Rate for Payer: United Healthcare All Payer |
$4,865.52
|
|
|
CYSTOSCOPY REMOVAL OF CLOTS(T
|
Facility
|
OP
|
$5,529.00
|
|
|
Service Code
|
HCPCS 52001
|
| Hospital Charge Code |
761T2082
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,901.42 |
| Max. Negotiated Rate |
$5,307.84 |
| Rate for Payer: Aetna Commercial |
$4,257.33
|
| Rate for Payer: Anthem Medicaid |
$1,901.42
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,186.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,312.62
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,461.49
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,302.15
|
| Rate for Payer: Cash Price |
$2,764.50
|
| Rate for Payer: Cash Price |
$2,764.50
|
| Rate for Payer: Cigna Commercial |
$4,589.07
|
| Rate for Payer: First Health Commercial |
$5,252.55
|
| Rate for Payer: Humana Commercial |
$4,699.65
|
| Rate for Payer: Humana KY Medicaid |
$1,901.42
|
| Rate for Payer: Humana Medicare Advantage |
$3,186.78
|
| Rate for Payer: Kentucky WC Medicaid |
$1,920.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,533.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,080.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,824.14
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,939.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,865.52
|
| Rate for Payer: Ohio Health Group HMO |
$4,146.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,423.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,810.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,815.01
|
| Rate for Payer: PHCS Commercial |
$5,307.84
|
| Rate for Payer: United Healthcare All Payer |
$4,865.52
|
|
|
CYSTOSCOPY & REVISE URETHRA
|
Facility
|
IP
|
$6,005.00
|
|
|
Service Code
|
HCPCS 52275
|
| Hospital Charge Code |
76102092
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,801.50 |
| Max. Negotiated Rate |
$5,764.80 |
| Rate for Payer: Aetna Commercial |
$4,623.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,683.90
|
| Rate for Payer: Cash Price |
$3,002.50
|
| Rate for Payer: Cigna Commercial |
$4,984.15
|
| Rate for Payer: First Health Commercial |
$5,704.75
|
| Rate for Payer: Humana Commercial |
$5,104.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,924.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,431.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,801.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,284.40
|
| Rate for Payer: Ohio Health Group HMO |
$4,503.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,804.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,224.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,143.45
|
| Rate for Payer: PHCS Commercial |
$5,764.80
|
| Rate for Payer: United Healthcare All Payer |
$5,284.40
|
|
|
CYSTOSCOPY & REVISE URETHRA
|
Facility
|
OP
|
$6,005.00
|
|
|
Service Code
|
HCPCS 52275
|
| Hospital Charge Code |
76102092
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,892.78 |
| Max. Negotiated Rate |
$5,764.80 |
| Rate for Payer: Aetna Commercial |
$4,623.85
|
| Rate for Payer: Anthem Medicaid |
$2,065.12
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,892.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,683.90
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,649.89
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,555.25
|
| Rate for Payer: Cash Price |
$3,002.50
|
| Rate for Payer: Cash Price |
$3,002.50
|
| Rate for Payer: Cigna Commercial |
$4,984.15
|
| Rate for Payer: First Health Commercial |
$5,704.75
|
| Rate for Payer: Humana Commercial |
$5,104.25
|
| Rate for Payer: Humana KY Medicaid |
$2,065.12
|
| Rate for Payer: Humana Medicare Advantage |
$1,892.78
|
| Rate for Payer: Kentucky WC Medicaid |
$2,086.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,924.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,431.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,271.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,106.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,284.40
|
| Rate for Payer: Ohio Health Group HMO |
$4,503.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,804.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,224.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,143.45
|
| Rate for Payer: PHCS Commercial |
$5,764.80
|
| Rate for Payer: United Healthcare All Payer |
$5,284.40
|
|
|
CYSTOSCOPY & REVISE URETHRA
|
Professional
|
Both
|
$6,005.00
|
|
|
Service Code
|
HCPCS 52275
|
| Hospital Charge Code |
76102092
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$124.58 |
| Max. Negotiated Rate |
$3,603.00 |
| Rate for Payer: Aetna Commercial |
$414.15
|
| Rate for Payer: Ambetter Exchange |
$233.56
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$124.58
|
| Rate for Payer: Anthem Medicaid |
$237.91
|
| Rate for Payer: Buckeye Individual/Medicaid |
$233.56
|
| Rate for Payer: Buckeye Medicare Advantage |
$233.56
|
| Rate for Payer: CareSource Just4Me Medicare |
$280.27
|
| Rate for Payer: Cash Price |
$3,002.50
|
| Rate for Payer: Cash Price |
$3,002.50
|
| Rate for Payer: Cigna Commercial |
$368.75
|
| Rate for Payer: Healthspan PPO |
$701.32
|
| Rate for Payer: Humana Medicaid |
$237.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$340.88
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$233.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$233.56
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$242.67
|
| Rate for Payer: Molina Healthcare Passport |
$237.91
|
| Rate for Payer: Multiplan PHCS |
$3,603.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$303.63
|
| Rate for Payer: UHCCP Medicaid |
$130.81
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$240.29
|
| Rate for Payer: Wellcare Medicare Advantage |
$233.56
|
|
|
CYSTOSCOPY & REVISE URETHRA(P
|
Professional
|
Both
|
$455.00
|
|
|
Service Code
|
HCPCS 52275
|
| Hospital Charge Code |
761P2092
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$124.58 |
| Max. Negotiated Rate |
$701.32 |
| Rate for Payer: Aetna Commercial |
$414.15
|
| Rate for Payer: Ambetter Exchange |
$233.56
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$124.58
|
| Rate for Payer: Anthem Medicaid |
$237.91
|
| Rate for Payer: Buckeye Individual/Medicaid |
$233.56
|
| Rate for Payer: Buckeye Medicare Advantage |
$233.56
|
| Rate for Payer: CareSource Just4Me Medicare |
$280.27
|
| Rate for Payer: Cash Price |
$227.50
|
| Rate for Payer: Cash Price |
$227.50
|
| Rate for Payer: Cigna Commercial |
$368.75
|
| Rate for Payer: Healthspan PPO |
$701.32
|
| Rate for Payer: Humana Medicaid |
$237.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$340.88
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$233.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$233.56
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$242.67
|
| Rate for Payer: Molina Healthcare Passport |
$237.91
|
| Rate for Payer: Multiplan PHCS |
$273.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$303.63
|
| Rate for Payer: UHCCP Medicaid |
$130.81
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$240.29
|
| Rate for Payer: Wellcare Medicare Advantage |
$233.56
|
|
|
CYSTOSCOPY & REVISE URETHRA(T
|
Facility
|
OP
|
$5,550.00
|
|
|
Service Code
|
HCPCS 52275
|
| Hospital Charge Code |
761T2092
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,892.78 |
| Max. Negotiated Rate |
$5,328.00 |
| Rate for Payer: Aetna Commercial |
$4,273.50
|
| Rate for Payer: Anthem Medicaid |
$1,908.64
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,892.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,329.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,649.89
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,555.25
|
| Rate for Payer: Cash Price |
$2,775.00
|
| Rate for Payer: Cash Price |
$2,775.00
|
| Rate for Payer: Cigna Commercial |
$4,606.50
|
| Rate for Payer: First Health Commercial |
$5,272.50
|
| Rate for Payer: Humana Commercial |
$4,717.50
|
| Rate for Payer: Humana KY Medicaid |
$1,908.64
|
| Rate for Payer: Humana Medicare Advantage |
$1,892.78
|
| Rate for Payer: Kentucky WC Medicaid |
$1,928.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,551.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,095.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,271.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,946.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,884.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,162.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,440.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,828.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,829.50
|
| Rate for Payer: PHCS Commercial |
$5,328.00
|
| Rate for Payer: United Healthcare All Payer |
$4,884.00
|
|
|
CYSTOSCOPY & REVISE URETHRA(T
|
Facility
|
IP
|
$5,550.00
|
|
|
Service Code
|
HCPCS 52275
|
| Hospital Charge Code |
761T2092
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,665.00 |
| Max. Negotiated Rate |
$5,328.00 |
| Rate for Payer: Aetna Commercial |
$4,273.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,329.00
|
| Rate for Payer: Cash Price |
$2,775.00
|
| Rate for Payer: Cigna Commercial |
$4,606.50
|
| Rate for Payer: First Health Commercial |
$5,272.50
|
| Rate for Payer: Humana Commercial |
$4,717.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,551.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,095.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,665.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,884.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,162.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,440.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,828.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,829.50
|
| Rate for Payer: PHCS Commercial |
$5,328.00
|
| Rate for Payer: United Healthcare All Payer |
$4,884.00
|
|
|
CYSTOSCOPY & URETER CATHETE(P
|
Professional
|
Both
|
$1,000.00
|
|
|
Service Code
|
HCPCS 52005
|
| Hospital Charge Code |
761P2083
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$66.62 |
| Max. Negotiated Rate |
$600.00 |
| Rate for Payer: Aetna Commercial |
$219.04
|
| Rate for Payer: Ambetter Exchange |
$125.25
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$66.62
|
| Rate for Payer: Anthem Medicaid |
$133.90
|
| Rate for Payer: Buckeye Individual/Medicaid |
$125.25
|
| Rate for Payer: Buckeye Medicare Advantage |
$125.25
|
| Rate for Payer: CareSource Just4Me Medicare |
$150.30
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cigna Commercial |
$191.64
|
| Rate for Payer: Healthspan PPO |
$362.16
|
| Rate for Payer: Humana Medicaid |
$133.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$181.86
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$125.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$125.25
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$136.58
|
| Rate for Payer: Molina Healthcare Passport |
$133.90
|
| Rate for Payer: Multiplan PHCS |
$600.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$162.82
|
| Rate for Payer: UHCCP Medicaid |
$69.95
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$135.24
|
| Rate for Payer: Wellcare Medicare Advantage |
$125.25
|
|
|
CYSTOSCOPY & URETER CATHETER
|
Professional
|
Both
|
$6,212.00
|
|
|
Service Code
|
HCPCS 52005
|
| Hospital Charge Code |
76102083
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$66.62 |
| Max. Negotiated Rate |
$3,727.20 |
| Rate for Payer: Aetna Commercial |
$219.04
|
| Rate for Payer: Ambetter Exchange |
$125.25
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$66.62
|
| Rate for Payer: Anthem Medicaid |
$133.90
|
| Rate for Payer: Buckeye Individual/Medicaid |
$125.25
|
| Rate for Payer: Buckeye Medicare Advantage |
$125.25
|
| Rate for Payer: CareSource Just4Me Medicare |
$150.30
|
| Rate for Payer: Cash Price |
$3,106.00
|
| Rate for Payer: Cash Price |
$3,106.00
|
| Rate for Payer: Cigna Commercial |
$191.64
|
| Rate for Payer: Healthspan PPO |
$362.16
|
| Rate for Payer: Humana Medicaid |
$133.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$181.86
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$125.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$125.25
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$136.58
|
| Rate for Payer: Molina Healthcare Passport |
$133.90
|
| Rate for Payer: Multiplan PHCS |
$3,727.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$162.82
|
| Rate for Payer: UHCCP Medicaid |
$69.95
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$135.24
|
| Rate for Payer: Wellcare Medicare Advantage |
$125.25
|
|
|
CYSTOSCOPY & URETER CATHETER
|
Facility
|
IP
|
$6,212.00
|
|
|
Service Code
|
HCPCS 52005
|
| Hospital Charge Code |
76102083
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,863.60 |
| Max. Negotiated Rate |
$5,963.52 |
| Rate for Payer: Aetna Commercial |
$4,783.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,845.36
|
| Rate for Payer: Cash Price |
$3,106.00
|
| Rate for Payer: Cigna Commercial |
$5,155.96
|
| Rate for Payer: First Health Commercial |
$5,901.40
|
| Rate for Payer: Humana Commercial |
$5,280.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,093.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,584.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,863.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,466.56
|
| Rate for Payer: Ohio Health Group HMO |
$4,659.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,969.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,404.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,286.28
|
| Rate for Payer: PHCS Commercial |
$5,963.52
|
| Rate for Payer: United Healthcare All Payer |
$5,466.56
|
|
|
CYSTOSCOPY & URETER CATHETER
|
Facility
|
OP
|
$6,212.00
|
|
|
Service Code
|
HCPCS 52005
|
| Hospital Charge Code |
76102083
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,892.78 |
| Max. Negotiated Rate |
$5,963.52 |
| Rate for Payer: Aetna Commercial |
$4,783.24
|
| Rate for Payer: Anthem Medicaid |
$2,136.31
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,892.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,845.36
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,649.89
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,555.25
|
| Rate for Payer: Cash Price |
$3,106.00
|
| Rate for Payer: Cash Price |
$3,106.00
|
| Rate for Payer: Cigna Commercial |
$5,155.96
|
| Rate for Payer: First Health Commercial |
$5,901.40
|
| Rate for Payer: Humana Commercial |
$5,280.20
|
| Rate for Payer: Humana KY Medicaid |
$2,136.31
|
| Rate for Payer: Humana Medicare Advantage |
$1,892.78
|
| Rate for Payer: Kentucky WC Medicaid |
$2,158.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,093.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,584.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,271.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,179.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,466.56
|
| Rate for Payer: Ohio Health Group HMO |
$4,659.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,969.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,404.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,286.28
|
| Rate for Payer: PHCS Commercial |
$5,963.52
|
| Rate for Payer: United Healthcare All Payer |
$5,466.56
|
|
|
CYSTOSCOPY & URETER CATHETE(T
|
Facility
|
IP
|
$5,212.00
|
|
|
Service Code
|
HCPCS 52005
|
| Hospital Charge Code |
761T2083
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,563.60 |
| Max. Negotiated Rate |
$5,003.52 |
| Rate for Payer: Aetna Commercial |
$4,013.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,065.36
|
| Rate for Payer: Cash Price |
$2,606.00
|
| Rate for Payer: Cigna Commercial |
$4,325.96
|
| Rate for Payer: First Health Commercial |
$4,951.40
|
| Rate for Payer: Humana Commercial |
$4,430.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,273.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,846.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,563.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,586.56
|
| Rate for Payer: Ohio Health Group HMO |
$3,909.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,169.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,534.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,596.28
|
| Rate for Payer: PHCS Commercial |
$5,003.52
|
| Rate for Payer: United Healthcare All Payer |
$4,586.56
|
|
|
CYSTOSCOPY & URETER CATHETE(T
|
Facility
|
OP
|
$5,212.00
|
|
|
Service Code
|
HCPCS 52005
|
| Hospital Charge Code |
761T2083
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,792.41 |
| Max. Negotiated Rate |
$5,003.52 |
| Rate for Payer: Aetna Commercial |
$4,013.24
|
| Rate for Payer: Anthem Medicaid |
$1,792.41
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,892.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,065.36
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,649.89
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,555.25
|
| Rate for Payer: Cash Price |
$2,606.00
|
| Rate for Payer: Cash Price |
$2,606.00
|
| Rate for Payer: Cigna Commercial |
$4,325.96
|
| Rate for Payer: First Health Commercial |
$4,951.40
|
| Rate for Payer: Humana Commercial |
$4,430.20
|
| Rate for Payer: Humana KY Medicaid |
$1,792.41
|
| Rate for Payer: Humana Medicare Advantage |
$1,892.78
|
| Rate for Payer: Kentucky WC Medicaid |
$1,810.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,273.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,846.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,271.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,828.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,586.56
|
| Rate for Payer: Ohio Health Group HMO |
$3,909.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,169.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,534.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,596.28
|
| Rate for Payer: PHCS Commercial |
$5,003.52
|
| Rate for Payer: United Healthcare All Payer |
$4,586.56
|
|
|
CYSTOSTO CYSTO W DRAINAGE
|
Facility
|
OP
|
$7,526.93
|
|
|
Service Code
|
HCPCS 51040
|
| Hospital Charge Code |
76102059
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,892.78 |
| Max. Negotiated Rate |
$7,225.85 |
| Rate for Payer: Aetna Commercial |
$5,795.74
|
| Rate for Payer: Anthem Medicaid |
$2,588.51
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,892.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,871.01
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,649.89
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,555.25
|
| Rate for Payer: Cash Price |
$3,763.47
|
| Rate for Payer: Cash Price |
$3,763.47
|
| Rate for Payer: Cigna Commercial |
$6,247.35
|
| Rate for Payer: First Health Commercial |
$7,150.58
|
| Rate for Payer: Humana Commercial |
$6,397.89
|
| Rate for Payer: Humana KY Medicaid |
$2,588.51
|
| Rate for Payer: Humana Medicare Advantage |
$1,892.78
|
| Rate for Payer: Kentucky WC Medicaid |
$2,614.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,172.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,554.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,271.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,640.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,623.70
|
| Rate for Payer: Ohio Health Group HMO |
$5,645.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,021.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,548.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,193.58
|
| Rate for Payer: PHCS Commercial |
$7,225.85
|
| Rate for Payer: United Healthcare All Payer |
$6,623.70
|
|
|
CYSTOSTO CYSTO W DRAINAGE
|
Professional
|
Both
|
$7,526.93
|
|
|
Service Code
|
HCPCS 51040
|
| Hospital Charge Code |
76102059
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$276.18 |
| Max. Negotiated Rate |
$4,516.16 |
| Rate for Payer: Aetna Commercial |
$467.82
|
| Rate for Payer: Ambetter Exchange |
$276.18
|
| Rate for Payer: Anthem Medicaid |
$278.22
|
| Rate for Payer: Buckeye Individual/Medicaid |
$276.18
|
| Rate for Payer: Buckeye Medicare Advantage |
$276.18
|
| Rate for Payer: CareSource Just4Me Medicare |
$331.42
|
| Rate for Payer: Cash Price |
$3,763.47
|
| Rate for Payer: Cash Price |
$3,763.47
|
| Rate for Payer: Cigna Commercial |
$418.53
|
| Rate for Payer: Healthspan PPO |
$374.07
|
| Rate for Payer: Humana Medicaid |
$278.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$393.38
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$276.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$276.18
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$283.78
|
| Rate for Payer: Molina Healthcare Passport |
$278.22
|
| Rate for Payer: Multiplan PHCS |
$4,516.16
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$359.03
|
| Rate for Payer: UHCCP Medicaid |
$2,634.43
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$281.00
|
| Rate for Payer: Wellcare Medicare Advantage |
$276.18
|
|
|
CYSTOSTO CYSTO W DRAINAGE
|
Facility
|
IP
|
$7,526.93
|
|
|
Service Code
|
HCPCS 51040
|
| Hospital Charge Code |
76102059
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,258.08 |
| Max. Negotiated Rate |
$7,225.85 |
| Rate for Payer: Aetna Commercial |
$5,795.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,871.01
|
| Rate for Payer: Cash Price |
$3,763.47
|
| Rate for Payer: Cigna Commercial |
$6,247.35
|
| Rate for Payer: First Health Commercial |
$7,150.58
|
| Rate for Payer: Humana Commercial |
$6,397.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,172.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,554.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,258.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,623.70
|
| Rate for Payer: Ohio Health Group HMO |
$5,645.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,021.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,548.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,193.58
|
| Rate for Payer: PHCS Commercial |
$7,225.85
|
| Rate for Payer: United Healthcare All Payer |
$6,623.70
|
|
|
CYSTOSTO CYSTO W DRAINAGE
|
Facility
|
OP
|
$5,826.93
|
|
|
Service Code
|
HCPCS 51040
|
| Hospital Charge Code |
45000277
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,892.78 |
| Max. Negotiated Rate |
$5,593.85 |
| Rate for Payer: Aetna Commercial |
$4,486.74
|
| Rate for Payer: Anthem Medicaid |
$2,003.88
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,892.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,545.01
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,649.89
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,555.25
|
| Rate for Payer: Cash Price |
$2,913.47
|
| Rate for Payer: Cash Price |
$2,913.47
|
| Rate for Payer: Cigna Commercial |
$4,836.35
|
| Rate for Payer: First Health Commercial |
$5,535.58
|
| Rate for Payer: Humana Commercial |
$4,952.89
|
| Rate for Payer: Humana KY Medicaid |
$2,003.88
|
| Rate for Payer: Humana Medicare Advantage |
$1,892.78
|
| Rate for Payer: Kentucky WC Medicaid |
$2,024.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,778.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,300.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,271.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,044.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,127.70
|
| Rate for Payer: Ohio Health Group HMO |
$4,370.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,661.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,069.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,020.58
|
| Rate for Payer: PHCS Commercial |
$5,593.85
|
| Rate for Payer: United Healthcare All Payer |
$5,127.70
|
|
|
CYSTOSTO CYSTO W DRAINAGE
|
Facility
|
IP
|
$5,826.93
|
|
|
Service Code
|
HCPCS 51040
|
| Hospital Charge Code |
45000277
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,748.08 |
| Max. Negotiated Rate |
$5,593.85 |
| Rate for Payer: Aetna Commercial |
$4,486.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,545.01
|
| Rate for Payer: Cash Price |
$2,913.47
|
| Rate for Payer: Cigna Commercial |
$4,836.35
|
| Rate for Payer: First Health Commercial |
$5,535.58
|
| Rate for Payer: Humana Commercial |
$4,952.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,778.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,300.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,748.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,127.70
|
| Rate for Payer: Ohio Health Group HMO |
$4,370.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,661.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,069.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,020.58
|
| Rate for Payer: PHCS Commercial |
$5,593.85
|
| Rate for Payer: United Healthcare All Payer |
$5,127.70
|
|
|
CYSTOSTO CYSTO W DRAINAGE(P
|
Professional
|
Both
|
$1,700.00
|
|
|
Service Code
|
HCPCS 51040
|
| Hospital Charge Code |
761P2059
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$276.18 |
| Max. Negotiated Rate |
$1,020.00 |
| Rate for Payer: Aetna Commercial |
$467.82
|
| Rate for Payer: Ambetter Exchange |
$276.18
|
| Rate for Payer: Anthem Medicaid |
$278.22
|
| Rate for Payer: Buckeye Individual/Medicaid |
$276.18
|
| Rate for Payer: Buckeye Medicare Advantage |
$276.18
|
| Rate for Payer: CareSource Just4Me Medicare |
$331.42
|
| Rate for Payer: Cash Price |
$850.00
|
| Rate for Payer: Cash Price |
$850.00
|
| Rate for Payer: Cigna Commercial |
$418.53
|
| Rate for Payer: Healthspan PPO |
$374.07
|
| Rate for Payer: Humana Medicaid |
$278.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$393.38
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$276.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$276.18
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$283.78
|
| Rate for Payer: Molina Healthcare Passport |
$278.22
|
| Rate for Payer: Multiplan PHCS |
$1,020.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$359.03
|
| Rate for Payer: UHCCP Medicaid |
$595.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$281.00
|
| Rate for Payer: Wellcare Medicare Advantage |
$276.18
|
|
|
CYSTOSTO CYSTO W DRAINAGE(T
|
Facility
|
IP
|
$5,826.93
|
|
|
Service Code
|
HCPCS 51040
|
| Hospital Charge Code |
761T2059
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,748.08 |
| Max. Negotiated Rate |
$5,593.85 |
| Rate for Payer: Aetna Commercial |
$4,486.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,545.01
|
| Rate for Payer: Cash Price |
$2,913.47
|
| Rate for Payer: Cigna Commercial |
$4,836.35
|
| Rate for Payer: First Health Commercial |
$5,535.58
|
| Rate for Payer: Humana Commercial |
$4,952.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,778.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,300.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,748.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,127.70
|
| Rate for Payer: Ohio Health Group HMO |
$4,370.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,661.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,069.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,020.58
|
| Rate for Payer: PHCS Commercial |
$5,593.85
|
| Rate for Payer: United Healthcare All Payer |
$5,127.70
|
|
