|
EXC BENIGN LESION 2.1-3.0 CM(T
|
Facility
|
OP
|
$3,553.00
|
|
|
Service Code
|
HCPCS 11423
|
| Hospital Charge Code |
761T0060
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,221.88 |
| Max. Negotiated Rate |
$3,410.88 |
| Rate for Payer: Aetna Commercial |
$2,735.81
|
| Rate for Payer: Anthem Medicaid |
$1,221.88
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,497.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,771.34
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,095.90
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,021.04
|
| Rate for Payer: Cash Price |
$1,776.50
|
| Rate for Payer: Cash Price |
$1,776.50
|
| Rate for Payer: Cigna Commercial |
$2,948.99
|
| Rate for Payer: First Health Commercial |
$3,375.35
|
| Rate for Payer: Humana Commercial |
$3,020.05
|
| Rate for Payer: Humana KY Medicaid |
$1,221.88
|
| Rate for Payer: Humana Medicare Advantage |
$1,497.07
|
| Rate for Payer: Kentucky WC Medicaid |
$1,234.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,913.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,622.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,796.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,246.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,126.64
|
| Rate for Payer: Ohio Health Group HMO |
$2,664.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,842.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,091.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,451.57
|
| Rate for Payer: PHCS Commercial |
$3,410.88
|
| Rate for Payer: United Healthcare All Payer |
$3,126.64
|
|
|
EXC BENIGN LESION 2.1-3.0 CM(T
|
Facility
|
IP
|
$3,553.00
|
|
|
Service Code
|
HCPCS 11423
|
| Hospital Charge Code |
761T0060
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,065.90 |
| Max. Negotiated Rate |
$3,410.88 |
| Rate for Payer: Aetna Commercial |
$2,735.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,771.34
|
| Rate for Payer: Cash Price |
$1,776.50
|
| Rate for Payer: Cigna Commercial |
$2,948.99
|
| Rate for Payer: First Health Commercial |
$3,375.35
|
| Rate for Payer: Humana Commercial |
$3,020.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,913.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,622.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,065.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,126.64
|
| Rate for Payer: Ohio Health Group HMO |
$2,664.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,842.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,091.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,451.57
|
| Rate for Payer: PHCS Commercial |
$3,410.88
|
| Rate for Payer: United Healthcare All Payer |
$3,126.64
|
|
|
EXC BENIGN MAXILLA TUM CYST
|
Facility
|
IP
|
$8,447.00
|
|
|
Service Code
|
HCPCS 21048
|
| Hospital Charge Code |
76100371
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,534.10 |
| Max. Negotiated Rate |
$8,109.12 |
| Rate for Payer: Aetna Commercial |
$6,504.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,588.66
|
| Rate for Payer: Cash Price |
$4,223.50
|
| Rate for Payer: Cigna Commercial |
$7,011.01
|
| Rate for Payer: First Health Commercial |
$8,024.65
|
| Rate for Payer: Humana Commercial |
$7,179.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,926.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,233.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,534.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,433.36
|
| Rate for Payer: Ohio Health Group HMO |
$6,335.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,757.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,348.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,828.43
|
| Rate for Payer: PHCS Commercial |
$8,109.12
|
| Rate for Payer: United Healthcare All Payer |
$7,433.36
|
|
|
EXC BENIGN MAXILLA TUM CYST
|
Facility
|
OP
|
$8,447.00
|
|
|
Service Code
|
HCPCS 21048
|
| Hospital Charge Code |
76100371
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,904.92 |
| Max. Negotiated Rate |
$8,109.12 |
| Rate for Payer: Aetna Commercial |
$6,504.19
|
| Rate for Payer: Anthem Medicaid |
$2,904.92
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5,465.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,588.66
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7,652.33
|
| Rate for Payer: CareSource Just4Me Medicare |
$7,379.03
|
| Rate for Payer: Cash Price |
$4,223.50
|
| Rate for Payer: Cash Price |
$4,223.50
|
| Rate for Payer: Cigna Commercial |
$7,011.01
|
| Rate for Payer: First Health Commercial |
$8,024.65
|
| Rate for Payer: Humana Commercial |
$7,179.95
|
| Rate for Payer: Humana KY Medicaid |
$2,904.92
|
| Rate for Payer: Humana Medicare Advantage |
$5,465.95
|
| Rate for Payer: Kentucky WC Medicaid |
$2,934.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,926.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,233.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,559.14
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,963.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,433.36
|
| Rate for Payer: Ohio Health Group HMO |
$6,335.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,757.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,348.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,828.43
|
| Rate for Payer: PHCS Commercial |
$8,109.12
|
| Rate for Payer: United Healthcare All Payer |
$7,433.36
|
|
|
EXC BENIGN MAXILLA TUM CYST
|
Professional
|
Both
|
$8,447.00
|
|
|
Service Code
|
HCPCS 21048
|
| Hospital Charge Code |
76100371
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$687.94 |
| Max. Negotiated Rate |
$5,068.20 |
| Rate for Payer: Aetna Commercial |
$1,592.37
|
| Rate for Payer: Ambetter Exchange |
$937.31
|
| Rate for Payer: Anthem Medicaid |
$687.94
|
| Rate for Payer: Buckeye Individual/Medicaid |
$937.31
|
| Rate for Payer: Buckeye Medicare Advantage |
$937.31
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,124.77
|
| Rate for Payer: Cash Price |
$4,223.50
|
| Rate for Payer: Cash Price |
$4,223.50
|
| Rate for Payer: Cigna Commercial |
$1,727.86
|
| Rate for Payer: Healthspan PPO |
$1,442.34
|
| Rate for Payer: Humana Medicaid |
$687.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,378.68
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$937.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$937.31
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$701.70
|
| Rate for Payer: Molina Healthcare Passport |
$687.94
|
| Rate for Payer: Multiplan PHCS |
$5,068.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,218.50
|
| Rate for Payer: UHCCP Medicaid |
$2,956.45
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$694.82
|
| Rate for Payer: Wellcare Medicare Advantage |
$937.31
|
|
|
EXC BENIGN MAXILLA TUM CYST(P
|
Professional
|
Both
|
$1,500.00
|
|
|
Service Code
|
HCPCS 21048
|
| Hospital Charge Code |
761P0371
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$525.00 |
| Max. Negotiated Rate |
$1,727.86 |
| Rate for Payer: Aetna Commercial |
$1,592.37
|
| Rate for Payer: Ambetter Exchange |
$937.31
|
| Rate for Payer: Anthem Medicaid |
$687.94
|
| Rate for Payer: Buckeye Individual/Medicaid |
$937.31
|
| Rate for Payer: Buckeye Medicare Advantage |
$937.31
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,124.77
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cigna Commercial |
$1,727.86
|
| Rate for Payer: Healthspan PPO |
$1,442.34
|
| Rate for Payer: Humana Medicaid |
$687.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,378.68
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$937.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$937.31
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$701.70
|
| Rate for Payer: Molina Healthcare Passport |
$687.94
|
| Rate for Payer: Multiplan PHCS |
$900.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,218.50
|
| Rate for Payer: UHCCP Medicaid |
$525.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$694.82
|
| Rate for Payer: Wellcare Medicare Advantage |
$937.31
|
|
|
EXC BENIGN MAXILLA TUM CYST(T
|
Facility
|
OP
|
$6,947.00
|
|
|
Service Code
|
HCPCS 21048
|
| Hospital Charge Code |
761T0371
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,389.07 |
| Max. Negotiated Rate |
$7,652.33 |
| Rate for Payer: Aetna Commercial |
$5,349.19
|
| Rate for Payer: Anthem Medicaid |
$2,389.07
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5,465.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,418.66
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7,652.33
|
| Rate for Payer: CareSource Just4Me Medicare |
$7,379.03
|
| Rate for Payer: Cash Price |
$3,473.50
|
| Rate for Payer: Cash Price |
$3,473.50
|
| Rate for Payer: Cigna Commercial |
$5,766.01
|
| Rate for Payer: First Health Commercial |
$6,599.65
|
| Rate for Payer: Humana Commercial |
$5,904.95
|
| Rate for Payer: Humana KY Medicaid |
$2,389.07
|
| Rate for Payer: Humana Medicare Advantage |
$5,465.95
|
| Rate for Payer: Kentucky WC Medicaid |
$2,413.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,696.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,126.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,559.14
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,437.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,113.36
|
| Rate for Payer: Ohio Health Group HMO |
$5,210.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,557.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,043.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,793.43
|
| Rate for Payer: PHCS Commercial |
$6,669.12
|
| Rate for Payer: United Healthcare All Payer |
$6,113.36
|
|
|
EXC BENIGN MAXILLA TUM CYST(T
|
Facility
|
IP
|
$6,947.00
|
|
|
Service Code
|
HCPCS 21048
|
| Hospital Charge Code |
761T0371
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,084.10 |
| Max. Negotiated Rate |
$6,669.12 |
| Rate for Payer: Aetna Commercial |
$5,349.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,418.66
|
| Rate for Payer: Cash Price |
$3,473.50
|
| Rate for Payer: Cigna Commercial |
$5,766.01
|
| Rate for Payer: First Health Commercial |
$6,599.65
|
| Rate for Payer: Humana Commercial |
$5,904.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,696.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,126.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,084.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,113.36
|
| Rate for Payer: Ohio Health Group HMO |
$5,210.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,557.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,043.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,793.43
|
| Rate for Payer: PHCS Commercial |
$6,669.12
|
| Rate for Payer: United Healthcare All Payer |
$6,113.36
|
|
|
EXC BEN LESION 1.1-2.0 CM
|
Facility
|
IP
|
$2,764.00
|
|
|
Service Code
|
HCPCS 11402
|
| Hospital Charge Code |
76100053
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$829.20 |
| Max. Negotiated Rate |
$2,653.44 |
| Rate for Payer: Aetna Commercial |
$2,128.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,155.92
|
| Rate for Payer: Cash Price |
$1,382.00
|
| Rate for Payer: Cigna Commercial |
$2,294.12
|
| Rate for Payer: First Health Commercial |
$2,625.80
|
| Rate for Payer: Humana Commercial |
$2,349.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,266.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,039.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$829.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,432.32
|
| Rate for Payer: Ohio Health Group HMO |
$2,073.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,211.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,404.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,907.16
|
| Rate for Payer: PHCS Commercial |
$2,653.44
|
| Rate for Payer: United Healthcare All Payer |
$2,432.32
|
|
|
EXC BEN LESION 1.1-2.0 CM
|
Professional
|
Both
|
$2,764.00
|
|
|
Service Code
|
HCPCS 11402
|
| Hospital Charge Code |
76100053
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$59.70 |
| Max. Negotiated Rate |
$1,658.40 |
| Rate for Payer: Aetna Commercial |
$155.46
|
| Rate for Payer: Ambetter Exchange |
$108.32
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$59.70
|
| Rate for Payer: Anthem Medicaid |
$71.83
|
| Rate for Payer: Buckeye Individual/Medicaid |
$108.32
|
| Rate for Payer: Buckeye Medicare Advantage |
$108.32
|
| Rate for Payer: CareSource Just4Me Medicare |
$129.98
|
| Rate for Payer: Cash Price |
$1,382.00
|
| Rate for Payer: Cash Price |
$1,382.00
|
| Rate for Payer: Cigna Commercial |
$207.57
|
| Rate for Payer: Healthspan PPO |
$173.94
|
| Rate for Payer: Humana Medicaid |
$71.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$138.77
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$108.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$108.32
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$73.27
|
| Rate for Payer: Molina Healthcare Passport |
$71.83
|
| Rate for Payer: Multiplan PHCS |
$1,658.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$140.82
|
| Rate for Payer: UHCCP Medicaid |
$62.69
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$72.55
|
| Rate for Payer: Wellcare Medicare Advantage |
$108.32
|
|
|
EXC BEN LESION 1.1-2.0 CM
|
Facility
|
OP
|
$2,764.00
|
|
|
Service Code
|
HCPCS 11402
|
| Hospital Charge Code |
76100053
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$650.10 |
| Max. Negotiated Rate |
$2,653.44 |
| Rate for Payer: Aetna Commercial |
$2,128.28
|
| Rate for Payer: Anthem Medicaid |
$950.54
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$650.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,155.92
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$910.14
|
| Rate for Payer: CareSource Just4Me Medicare |
$877.63
|
| Rate for Payer: Cash Price |
$1,382.00
|
| Rate for Payer: Cash Price |
$1,382.00
|
| Rate for Payer: Cigna Commercial |
$2,294.12
|
| Rate for Payer: First Health Commercial |
$2,625.80
|
| Rate for Payer: Humana Commercial |
$2,349.40
|
| Rate for Payer: Humana KY Medicaid |
$950.54
|
| Rate for Payer: Humana Medicare Advantage |
$650.10
|
| Rate for Payer: Kentucky WC Medicaid |
$960.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,266.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,039.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$780.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$969.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,432.32
|
| Rate for Payer: Ohio Health Group HMO |
$2,073.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,211.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,404.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,907.16
|
| Rate for Payer: PHCS Commercial |
$2,653.44
|
| Rate for Payer: United Healthcare All Payer |
$2,432.32
|
|
|
EXC BEN LESION 1.1-2.0 CM(P
|
Professional
|
Both
|
$350.00
|
|
|
Service Code
|
HCPCS 11402
|
| Hospital Charge Code |
761P0053
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$59.70 |
| Max. Negotiated Rate |
$210.00 |
| Rate for Payer: Aetna Commercial |
$155.46
|
| Rate for Payer: Ambetter Exchange |
$108.32
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$59.70
|
| Rate for Payer: Anthem Medicaid |
$71.83
|
| Rate for Payer: Buckeye Individual/Medicaid |
$108.32
|
| Rate for Payer: Buckeye Medicare Advantage |
$108.32
|
| Rate for Payer: CareSource Just4Me Medicare |
$129.98
|
| Rate for Payer: Cash Price |
$175.00
|
| Rate for Payer: Cash Price |
$175.00
|
| Rate for Payer: Cigna Commercial |
$207.57
|
| Rate for Payer: Healthspan PPO |
$173.94
|
| Rate for Payer: Humana Medicaid |
$71.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$138.77
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$108.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$108.32
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$73.27
|
| Rate for Payer: Molina Healthcare Passport |
$71.83
|
| Rate for Payer: Multiplan PHCS |
$210.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$140.82
|
| Rate for Payer: UHCCP Medicaid |
$62.69
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$72.55
|
| Rate for Payer: Wellcare Medicare Advantage |
$108.32
|
|
|
EXC BEN LESION 1.1-2.0 CM(T
|
Facility
|
OP
|
$2,414.00
|
|
|
Service Code
|
HCPCS 11402
|
| Hospital Charge Code |
761T0053
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$650.10 |
| Max. Negotiated Rate |
$2,317.44 |
| Rate for Payer: Aetna Commercial |
$1,858.78
|
| Rate for Payer: Anthem Medicaid |
$830.17
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$650.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,882.92
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$910.14
|
| Rate for Payer: CareSource Just4Me Medicare |
$877.63
|
| Rate for Payer: Cash Price |
$1,207.00
|
| Rate for Payer: Cash Price |
$1,207.00
|
| Rate for Payer: Cigna Commercial |
$2,003.62
|
| Rate for Payer: First Health Commercial |
$2,293.30
|
| Rate for Payer: Humana Commercial |
$2,051.90
|
| Rate for Payer: Humana KY Medicaid |
$830.17
|
| Rate for Payer: Humana Medicare Advantage |
$650.10
|
| Rate for Payer: Kentucky WC Medicaid |
$838.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,979.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,781.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$780.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$846.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,124.32
|
| Rate for Payer: Ohio Health Group HMO |
$1,810.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,931.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,100.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,665.66
|
| Rate for Payer: PHCS Commercial |
$2,317.44
|
| Rate for Payer: United Healthcare All Payer |
$2,124.32
|
|
|
EXC BEN LESION 1.1-2.0 CM(T
|
Facility
|
IP
|
$2,414.00
|
|
|
Service Code
|
HCPCS 11402
|
| Hospital Charge Code |
761T0053
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$724.20 |
| Max. Negotiated Rate |
$2,317.44 |
| Rate for Payer: Aetna Commercial |
$1,858.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,882.92
|
| Rate for Payer: Cash Price |
$1,207.00
|
| Rate for Payer: Cigna Commercial |
$2,003.62
|
| Rate for Payer: First Health Commercial |
$2,293.30
|
| Rate for Payer: Humana Commercial |
$2,051.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,979.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,781.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$724.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,124.32
|
| Rate for Payer: Ohio Health Group HMO |
$1,810.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,931.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,100.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,665.66
|
| Rate for Payer: PHCS Commercial |
$2,317.44
|
| Rate for Payer: United Healthcare All Payer |
$2,124.32
|
|
|
EXC BEN LESION 2.1-3.0 CM
|
Professional
|
Both
|
$3,235.00
|
|
|
Service Code
|
HCPCS 11403
|
| Hospital Charge Code |
76100054
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$75.27 |
| Max. Negotiated Rate |
$1,941.00 |
| Rate for Payer: Aetna Commercial |
$197.94
|
| Rate for Payer: Ambetter Exchange |
$141.07
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$75.27
|
| Rate for Payer: Anthem Medicaid |
$89.41
|
| Rate for Payer: Buckeye Individual/Medicaid |
$141.07
|
| Rate for Payer: Buckeye Medicare Advantage |
$141.07
|
| Rate for Payer: CareSource Just4Me Medicare |
$169.28
|
| Rate for Payer: Cash Price |
$1,617.50
|
| Rate for Payer: Cash Price |
$1,617.50
|
| Rate for Payer: Cigna Commercial |
$239.86
|
| Rate for Payer: Healthspan PPO |
$201.08
|
| Rate for Payer: Humana Medicaid |
$89.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$176.89
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$141.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$141.07
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$91.20
|
| Rate for Payer: Molina Healthcare Passport |
$89.41
|
| Rate for Payer: Multiplan PHCS |
$1,941.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$183.39
|
| Rate for Payer: UHCCP Medicaid |
$79.03
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$90.30
|
| Rate for Payer: Wellcare Medicare Advantage |
$141.07
|
|
|
EXC BEN LESION 2.1-3.0 CM
|
Facility
|
OP
|
$3,235.00
|
|
|
Service Code
|
HCPCS 11403
|
| Hospital Charge Code |
76100054
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$650.10 |
| Max. Negotiated Rate |
$3,105.60 |
| Rate for Payer: Aetna Commercial |
$2,490.95
|
| Rate for Payer: Anthem Medicaid |
$1,112.52
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$650.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,523.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$910.14
|
| Rate for Payer: CareSource Just4Me Medicare |
$877.63
|
| Rate for Payer: Cash Price |
$1,617.50
|
| Rate for Payer: Cash Price |
$1,617.50
|
| Rate for Payer: Cigna Commercial |
$2,685.05
|
| Rate for Payer: First Health Commercial |
$3,073.25
|
| Rate for Payer: Humana Commercial |
$2,749.75
|
| Rate for Payer: Humana KY Medicaid |
$1,112.52
|
| Rate for Payer: Humana Medicare Advantage |
$650.10
|
| Rate for Payer: Kentucky WC Medicaid |
$1,123.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,652.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,387.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$780.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,134.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,846.80
|
| Rate for Payer: Ohio Health Group HMO |
$2,426.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,588.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,814.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,232.15
|
| Rate for Payer: PHCS Commercial |
$3,105.60
|
| Rate for Payer: United Healthcare All Payer |
$2,846.80
|
|
|
EXC BEN LESION 2.1-3.0 CM
|
Facility
|
IP
|
$3,235.00
|
|
|
Service Code
|
HCPCS 11403
|
| Hospital Charge Code |
76100054
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$970.50 |
| Max. Negotiated Rate |
$3,105.60 |
| Rate for Payer: Aetna Commercial |
$2,490.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,523.30
|
| Rate for Payer: Cash Price |
$1,617.50
|
| Rate for Payer: Cigna Commercial |
$2,685.05
|
| Rate for Payer: First Health Commercial |
$3,073.25
|
| Rate for Payer: Humana Commercial |
$2,749.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,652.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,387.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$970.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,846.80
|
| Rate for Payer: Ohio Health Group HMO |
$2,426.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,588.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,814.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,232.15
|
| Rate for Payer: PHCS Commercial |
$3,105.60
|
| Rate for Payer: United Healthcare All Payer |
$2,846.80
|
|
|
EXC BEN LESION 2.1-3.0 CM(P
|
Professional
|
Both
|
$400.00
|
|
|
Service Code
|
HCPCS 11403
|
| Hospital Charge Code |
761P0054
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$75.27 |
| Max. Negotiated Rate |
$240.00 |
| Rate for Payer: Aetna Commercial |
$197.94
|
| Rate for Payer: Ambetter Exchange |
$141.07
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$75.27
|
| Rate for Payer: Anthem Medicaid |
$89.41
|
| Rate for Payer: Buckeye Individual/Medicaid |
$141.07
|
| Rate for Payer: Buckeye Medicare Advantage |
$141.07
|
| Rate for Payer: CareSource Just4Me Medicare |
$169.28
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cigna Commercial |
$239.86
|
| Rate for Payer: Healthspan PPO |
$201.08
|
| Rate for Payer: Humana Medicaid |
$89.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$176.89
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$141.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$141.07
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$91.20
|
| Rate for Payer: Molina Healthcare Passport |
$89.41
|
| Rate for Payer: Multiplan PHCS |
$240.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$183.39
|
| Rate for Payer: UHCCP Medicaid |
$79.03
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$90.30
|
| Rate for Payer: Wellcare Medicare Advantage |
$141.07
|
|
|
EXC BEN LESION 2.1-3.0 CM(T
|
Facility
|
IP
|
$2,835.00
|
|
|
Service Code
|
HCPCS 11403
|
| Hospital Charge Code |
761T0054
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$850.50 |
| Max. Negotiated Rate |
$2,721.60 |
| Rate for Payer: Aetna Commercial |
$2,182.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,211.30
|
| Rate for Payer: Cash Price |
$1,417.50
|
| Rate for Payer: Cigna Commercial |
$2,353.05
|
| Rate for Payer: First Health Commercial |
$2,693.25
|
| Rate for Payer: Humana Commercial |
$2,409.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,324.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,092.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$850.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,494.80
|
| Rate for Payer: Ohio Health Group HMO |
$2,126.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,268.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,466.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,956.15
|
| Rate for Payer: PHCS Commercial |
$2,721.60
|
| Rate for Payer: United Healthcare All Payer |
$2,494.80
|
|
|
EXC BEN LESION 2.1-3.0 CM(T
|
Facility
|
OP
|
$2,835.00
|
|
|
Service Code
|
HCPCS 11403
|
| Hospital Charge Code |
761T0054
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$650.10 |
| Max. Negotiated Rate |
$2,721.60 |
| Rate for Payer: Aetna Commercial |
$2,182.95
|
| Rate for Payer: Anthem Medicaid |
$974.96
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$650.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,211.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$910.14
|
| Rate for Payer: CareSource Just4Me Medicare |
$877.63
|
| Rate for Payer: Cash Price |
$1,417.50
|
| Rate for Payer: Cash Price |
$1,417.50
|
| Rate for Payer: Cigna Commercial |
$2,353.05
|
| Rate for Payer: First Health Commercial |
$2,693.25
|
| Rate for Payer: Humana Commercial |
$2,409.75
|
| Rate for Payer: Humana KY Medicaid |
$974.96
|
| Rate for Payer: Humana Medicare Advantage |
$650.10
|
| Rate for Payer: Kentucky WC Medicaid |
$984.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,324.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,092.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$780.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$994.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,494.80
|
| Rate for Payer: Ohio Health Group HMO |
$2,126.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,268.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,466.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,956.15
|
| Rate for Payer: PHCS Commercial |
$2,721.60
|
| Rate for Payer: United Healthcare All Payer |
$2,494.80
|
|
|
EXC BEN LESION 3.1-4.0 CM
|
Facility
|
IP
|
$3,955.00
|
|
|
Service Code
|
HCPCS 11404
|
| Hospital Charge Code |
76100055
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,186.50 |
| Max. Negotiated Rate |
$3,796.80 |
| Rate for Payer: Aetna Commercial |
$3,045.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,084.90
|
| Rate for Payer: Cash Price |
$1,977.50
|
| Rate for Payer: Cigna Commercial |
$3,282.65
|
| Rate for Payer: First Health Commercial |
$3,757.25
|
| Rate for Payer: Humana Commercial |
$3,361.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,243.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,918.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,186.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,480.40
|
| Rate for Payer: Ohio Health Group HMO |
$2,966.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,164.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,440.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,728.95
|
| Rate for Payer: PHCS Commercial |
$3,796.80
|
| Rate for Payer: United Healthcare All Payer |
$3,480.40
|
|
|
EXC BEN LESION 3.1-4.0 CM
|
Professional
|
Both
|
$3,955.00
|
|
|
Service Code
|
HCPCS 11404
|
| Hospital Charge Code |
76100055
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$83.40 |
| Max. Negotiated Rate |
$2,373.00 |
| Rate for Payer: Aetna Commercial |
$221.20
|
| Rate for Payer: Ambetter Exchange |
$155.72
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$83.40
|
| Rate for Payer: Anthem Medicaid |
$104.23
|
| Rate for Payer: Buckeye Individual/Medicaid |
$155.72
|
| Rate for Payer: Buckeye Medicare Advantage |
$155.72
|
| Rate for Payer: CareSource Just4Me Medicare |
$186.86
|
| Rate for Payer: Cash Price |
$1,977.50
|
| Rate for Payer: Cash Price |
$1,977.50
|
| Rate for Payer: Cigna Commercial |
$273.40
|
| Rate for Payer: Healthspan PPO |
$229.50
|
| Rate for Payer: Humana Medicaid |
$104.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$196.35
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$155.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$155.72
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$106.31
|
| Rate for Payer: Molina Healthcare Passport |
$104.23
|
| Rate for Payer: Multiplan PHCS |
$2,373.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$202.44
|
| Rate for Payer: UHCCP Medicaid |
$87.57
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$105.27
|
| Rate for Payer: Wellcare Medicare Advantage |
$155.72
|
|
|
EXC BEN LESION 3.1-4.0 CM
|
Facility
|
OP
|
$3,955.00
|
|
|
Service Code
|
HCPCS 11404
|
| Hospital Charge Code |
76100055
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,360.12 |
| Max. Negotiated Rate |
$3,796.80 |
| Rate for Payer: Aetna Commercial |
$3,045.35
|
| Rate for Payer: Anthem Medicaid |
$1,360.12
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,497.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,084.90
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,095.90
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,021.04
|
| Rate for Payer: Cash Price |
$1,977.50
|
| Rate for Payer: Cash Price |
$1,977.50
|
| Rate for Payer: Cigna Commercial |
$3,282.65
|
| Rate for Payer: First Health Commercial |
$3,757.25
|
| Rate for Payer: Humana Commercial |
$3,361.75
|
| Rate for Payer: Humana KY Medicaid |
$1,360.12
|
| Rate for Payer: Humana Medicare Advantage |
$1,497.07
|
| Rate for Payer: Kentucky WC Medicaid |
$1,373.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,243.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,918.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,796.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,387.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,480.40
|
| Rate for Payer: Ohio Health Group HMO |
$2,966.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,164.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,440.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,728.95
|
| Rate for Payer: PHCS Commercial |
$3,796.80
|
| Rate for Payer: United Healthcare All Payer |
$3,480.40
|
|
|
EXC BEN LESION 3.1-4.0 CM
|
Facility
|
IP
|
$4,207.00
|
|
|
Service Code
|
HCPCS 11424
|
| Hospital Charge Code |
76100061
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,262.10 |
| Max. Negotiated Rate |
$4,038.72 |
| Rate for Payer: Aetna Commercial |
$3,239.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,281.46
|
| Rate for Payer: Cash Price |
$2,103.50
|
| Rate for Payer: Cigna Commercial |
$3,491.81
|
| Rate for Payer: First Health Commercial |
$3,996.65
|
| Rate for Payer: Humana Commercial |
$3,575.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,449.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,104.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,262.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,702.16
|
| Rate for Payer: Ohio Health Group HMO |
$3,155.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,365.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,660.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,902.83
|
| Rate for Payer: PHCS Commercial |
$4,038.72
|
| Rate for Payer: United Healthcare All Payer |
$3,702.16
|
|
|
EXC BEN LESION 3.1-4.0 CM
|
Facility
|
OP
|
$4,207.00
|
|
|
Service Code
|
HCPCS 11424
|
| Hospital Charge Code |
76100061
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,446.79 |
| Max. Negotiated Rate |
$4,038.72 |
| Rate for Payer: Aetna Commercial |
$3,239.39
|
| Rate for Payer: Anthem Medicaid |
$1,446.79
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,497.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,281.46
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,095.90
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,021.04
|
| Rate for Payer: Cash Price |
$2,103.50
|
| Rate for Payer: Cash Price |
$2,103.50
|
| Rate for Payer: Cigna Commercial |
$3,491.81
|
| Rate for Payer: First Health Commercial |
$3,996.65
|
| Rate for Payer: Humana Commercial |
$3,575.95
|
| Rate for Payer: Humana KY Medicaid |
$1,446.79
|
| Rate for Payer: Humana Medicare Advantage |
$1,497.07
|
| Rate for Payer: Kentucky WC Medicaid |
$1,461.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,449.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,104.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,796.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,475.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,702.16
|
| Rate for Payer: Ohio Health Group HMO |
$3,155.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,365.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,660.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,902.83
|
| Rate for Payer: PHCS Commercial |
$4,038.72
|
| Rate for Payer: United Healthcare All Payer |
$3,702.16
|
|
