|
EXC FACE TUM DEEP 2 CM/>(P
|
Professional
|
Both
|
$870.00
|
|
|
Service Code
|
HCPCS 21014
|
| Hospital Charge Code |
761P0365
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$304.50 |
| Max. Negotiated Rate |
$907.38 |
| Rate for Payer: Aetna Commercial |
$792.73
|
| Rate for Payer: Ambetter Exchange |
$494.06
|
| Rate for Payer: Anthem Medicaid |
$376.05
|
| Rate for Payer: Buckeye Individual/Medicaid |
$494.06
|
| Rate for Payer: Buckeye Medicare Advantage |
$494.06
|
| Rate for Payer: CareSource Just4Me Medicare |
$592.87
|
| Rate for Payer: Cash Price |
$435.00
|
| Rate for Payer: Cash Price |
$435.00
|
| Rate for Payer: Cigna Commercial |
$907.38
|
| Rate for Payer: Healthspan PPO |
$565.43
|
| Rate for Payer: Humana Medicaid |
$376.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$665.55
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$494.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$494.06
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$383.57
|
| Rate for Payer: Molina Healthcare Passport |
$376.05
|
| Rate for Payer: Multiplan PHCS |
$522.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$642.28
|
| Rate for Payer: UHCCP Medicaid |
$304.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$379.81
|
| Rate for Payer: Wellcare Medicare Advantage |
$494.06
|
|
|
EXC FACE TUM DEEP < 2 CM(T
|
Facility
|
IP
|
$4,858.00
|
|
|
Service Code
|
HCPCS 21013
|
| Hospital Charge Code |
761T0364
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,457.40 |
| Max. Negotiated Rate |
$4,663.68 |
| Rate for Payer: Aetna Commercial |
$3,740.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,789.24
|
| Rate for Payer: Cash Price |
$2,429.00
|
| Rate for Payer: Cigna Commercial |
$4,032.14
|
| Rate for Payer: First Health Commercial |
$4,615.10
|
| Rate for Payer: Humana Commercial |
$4,129.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,983.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,585.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,457.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,275.04
|
| Rate for Payer: Ohio Health Group HMO |
$3,643.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,886.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,226.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,352.02
|
| Rate for Payer: PHCS Commercial |
$4,663.68
|
| Rate for Payer: United Healthcare All Payer |
$4,275.04
|
|
|
EXC FACE TUM DEEP < 2 CM(T
|
Facility
|
OP
|
$4,858.00
|
|
|
Service Code
|
HCPCS 21013
|
| Hospital Charge Code |
761T0364
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,497.07 |
| Max. Negotiated Rate |
$4,663.68 |
| Rate for Payer: Aetna Commercial |
$3,740.66
|
| Rate for Payer: Anthem Medicaid |
$1,670.67
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,497.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,789.24
|
| 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 |
$2,429.00
|
| Rate for Payer: Cash Price |
$2,429.00
|
| Rate for Payer: Cigna Commercial |
$4,032.14
|
| Rate for Payer: First Health Commercial |
$4,615.10
|
| Rate for Payer: Humana Commercial |
$4,129.30
|
| Rate for Payer: Humana KY Medicaid |
$1,670.67
|
| Rate for Payer: Humana Medicare Advantage |
$1,497.07
|
| Rate for Payer: Kentucky WC Medicaid |
$1,687.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,983.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,585.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,796.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,704.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,275.04
|
| Rate for Payer: Ohio Health Group HMO |
$3,643.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,886.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,226.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,352.02
|
| Rate for Payer: PHCS Commercial |
$4,663.68
|
| Rate for Payer: United Healthcare All Payer |
$4,275.04
|
|
|
EXC FACE TUM DEEP 2 CM/>(T
|
Facility
|
IP
|
$5,672.00
|
|
|
Service Code
|
HCPCS 21014
|
| Hospital Charge Code |
761T0365
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,701.60 |
| Max. Negotiated Rate |
$5,445.12 |
| Rate for Payer: Aetna Commercial |
$4,367.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,424.16
|
| Rate for Payer: Cash Price |
$2,836.00
|
| Rate for Payer: Cigna Commercial |
$4,707.76
|
| Rate for Payer: First Health Commercial |
$5,388.40
|
| Rate for Payer: Humana Commercial |
$4,821.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,651.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,185.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,701.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,991.36
|
| Rate for Payer: Ohio Health Group HMO |
$4,254.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,537.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,934.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,913.68
|
| Rate for Payer: PHCS Commercial |
$5,445.12
|
| Rate for Payer: United Healthcare All Payer |
$4,991.36
|
|
|
EXC FACE TUM DEEP 2 CM/>(T
|
Facility
|
OP
|
$5,672.00
|
|
|
Service Code
|
HCPCS 21014
|
| Hospital Charge Code |
761T0365
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,950.60 |
| Max. Negotiated Rate |
$5,445.12 |
| Rate for Payer: Aetna Commercial |
$4,367.44
|
| Rate for Payer: Anthem Medicaid |
$1,950.60
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,644.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,424.16
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,702.27
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,570.05
|
| Rate for Payer: Cash Price |
$2,836.00
|
| Rate for Payer: Cash Price |
$2,836.00
|
| Rate for Payer: Cigna Commercial |
$4,707.76
|
| Rate for Payer: First Health Commercial |
$5,388.40
|
| Rate for Payer: Humana Commercial |
$4,821.20
|
| Rate for Payer: Humana KY Medicaid |
$1,950.60
|
| Rate for Payer: Humana Medicare Advantage |
$2,644.48
|
| Rate for Payer: Kentucky WC Medicaid |
$1,970.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,651.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,185.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,173.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,989.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,991.36
|
| Rate for Payer: Ohio Health Group HMO |
$4,254.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,537.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,934.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,913.68
|
| Rate for Payer: PHCS Commercial |
$5,445.12
|
| Rate for Payer: United Healthcare All Payer |
$4,991.36
|
|
|
EXC FOOT/TOE TUM DEEP <1.5CM
|
Professional
|
Both
|
$483.14
|
|
|
Service Code
|
HCPCS 28045
|
| Hospital Charge Code |
761P2639
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$175.46 |
| Max. Negotiated Rate |
$605.16 |
| Rate for Payer: Aetna Commercial |
$497.90
|
| Rate for Payer: Ambetter Exchange |
$331.61
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$175.46
|
| Rate for Payer: Anthem Medicaid |
$249.07
|
| Rate for Payer: Buckeye Individual/Medicaid |
$331.61
|
| Rate for Payer: Buckeye Medicare Advantage |
$331.61
|
| Rate for Payer: CareSource Just4Me Medicare |
$397.93
|
| Rate for Payer: Cash Price |
$241.57
|
| Rate for Payer: Cash Price |
$241.57
|
| Rate for Payer: Cigna Commercial |
$546.71
|
| Rate for Payer: Healthspan PPO |
$605.16
|
| Rate for Payer: Humana Medicaid |
$249.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$435.49
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$331.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$331.61
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$254.05
|
| Rate for Payer: Molina Healthcare Passport |
$249.07
|
| Rate for Payer: Multiplan PHCS |
$289.88
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$431.09
|
| Rate for Payer: UHCCP Medicaid |
$184.23
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$251.56
|
| Rate for Payer: Wellcare Medicare Advantage |
$331.61
|
|
|
EXC FOOT/TOE TUM DEP 1.5CM/>
|
Professional
|
Both
|
$655.00
|
|
|
Service Code
|
HCPCS 28041
|
| Hospital Charge Code |
76102605
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$229.25 |
| Max. Negotiated Rate |
$785.96 |
| Rate for Payer: Aetna Commercial |
$683.92
|
| Rate for Payer: Ambetter Exchange |
$427.47
|
| Rate for Payer: Anthem Medicaid |
$328.28
|
| Rate for Payer: Buckeye Individual/Medicaid |
$427.47
|
| Rate for Payer: Buckeye Medicare Advantage |
$427.47
|
| Rate for Payer: CareSource Just4Me Medicare |
$512.96
|
| Rate for Payer: Cash Price |
$327.50
|
| Rate for Payer: Cash Price |
$327.50
|
| Rate for Payer: Cigna Commercial |
$785.96
|
| Rate for Payer: Healthspan PPO |
$487.37
|
| Rate for Payer: Humana Medicaid |
$328.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$555.11
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$427.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$427.47
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$334.85
|
| Rate for Payer: Molina Healthcare Passport |
$328.28
|
| Rate for Payer: Multiplan PHCS |
$393.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$555.71
|
| Rate for Payer: UHCCP Medicaid |
$229.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$331.56
|
| Rate for Payer: Wellcare Medicare Advantage |
$427.47
|
|
|
EXC FOOT/TOE TUM DEP 1.5CM/>
|
Facility
|
IP
|
$655.00
|
|
|
Service Code
|
HCPCS 28041
|
| Hospital Charge Code |
76102605
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$196.50 |
| Max. Negotiated Rate |
$628.80 |
| Rate for Payer: Aetna Commercial |
$504.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$510.90
|
| Rate for Payer: Cash Price |
$327.50
|
| Rate for Payer: Cigna Commercial |
$543.65
|
| Rate for Payer: First Health Commercial |
$622.25
|
| Rate for Payer: Humana Commercial |
$556.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$537.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$483.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$196.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$576.40
|
| Rate for Payer: Ohio Health Group HMO |
$491.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$524.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$569.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$451.95
|
| Rate for Payer: PHCS Commercial |
$628.80
|
| Rate for Payer: United Healthcare All Payer |
$576.40
|
|
|
EXC FOOT/TOE TUM DEP 1.5CM/>
|
Professional
|
Both
|
$655.00
|
|
|
Service Code
|
HCPCS 28041
|
| Hospital Charge Code |
761P2605
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$229.25 |
| Max. Negotiated Rate |
$785.96 |
| Rate for Payer: Aetna Commercial |
$683.92
|
| Rate for Payer: Ambetter Exchange |
$427.47
|
| Rate for Payer: Anthem Medicaid |
$328.28
|
| Rate for Payer: Buckeye Individual/Medicaid |
$427.47
|
| Rate for Payer: Buckeye Medicare Advantage |
$427.47
|
| Rate for Payer: CareSource Just4Me Medicare |
$512.96
|
| Rate for Payer: Cash Price |
$327.50
|
| Rate for Payer: Cash Price |
$327.50
|
| Rate for Payer: Cigna Commercial |
$785.96
|
| Rate for Payer: Healthspan PPO |
$487.37
|
| Rate for Payer: Humana Medicaid |
$328.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$555.11
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$427.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$427.47
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$334.85
|
| Rate for Payer: Molina Healthcare Passport |
$328.28
|
| Rate for Payer: Multiplan PHCS |
$393.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$555.71
|
| Rate for Payer: UHCCP Medicaid |
$229.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$331.56
|
| Rate for Payer: Wellcare Medicare Advantage |
$427.47
|
|
|
EXC FOOT/TOE TUM DEP 1.5CM/>
|
Facility
|
OP
|
$655.00
|
|
|
Service Code
|
HCPCS 28041
|
| Hospital Charge Code |
76102605
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$225.25 |
| Max. Negotiated Rate |
$3,702.27 |
| Rate for Payer: Aetna Commercial |
$504.35
|
| Rate for Payer: Anthem Medicaid |
$225.25
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,644.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$510.90
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,702.27
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,570.05
|
| Rate for Payer: Cash Price |
$327.50
|
| Rate for Payer: Cash Price |
$327.50
|
| Rate for Payer: Cigna Commercial |
$543.65
|
| Rate for Payer: First Health Commercial |
$622.25
|
| Rate for Payer: Humana Commercial |
$556.75
|
| Rate for Payer: Humana KY Medicaid |
$225.25
|
| Rate for Payer: Humana Medicare Advantage |
$2,644.48
|
| Rate for Payer: Kentucky WC Medicaid |
$227.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$537.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$483.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,173.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$229.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$576.40
|
| Rate for Payer: Ohio Health Group HMO |
$491.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$524.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$569.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$451.95
|
| Rate for Payer: PHCS Commercial |
$628.80
|
| Rate for Payer: United Healthcare All Payer |
$576.40
|
|
|
EXC FOOT/TOE TUM SC < 1.5 CM
|
Facility
|
OP
|
$5,076.45
|
|
|
Service Code
|
HCPCS 28043
|
| Hospital Charge Code |
76100970
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,497.07 |
| Max. Negotiated Rate |
$4,873.39 |
| Rate for Payer: Aetna Commercial |
$3,908.87
|
| Rate for Payer: Anthem Medicaid |
$1,745.79
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,497.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,959.63
|
| 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 |
$2,538.22
|
| Rate for Payer: Cash Price |
$2,538.22
|
| Rate for Payer: Cigna Commercial |
$4,213.45
|
| Rate for Payer: First Health Commercial |
$4,822.63
|
| Rate for Payer: Humana Commercial |
$4,314.98
|
| Rate for Payer: Humana KY Medicaid |
$1,745.79
|
| Rate for Payer: Humana Medicare Advantage |
$1,497.07
|
| Rate for Payer: Kentucky WC Medicaid |
$1,763.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,162.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,746.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,796.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,780.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,467.28
|
| Rate for Payer: Ohio Health Group HMO |
$3,807.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,061.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,416.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,502.75
|
| Rate for Payer: PHCS Commercial |
$4,873.39
|
| Rate for Payer: United Healthcare All Payer |
$4,467.28
|
|
|
EXC FOOT/TOE TUM SC < 1.5 CM
|
Professional
|
Both
|
$5,076.45
|
|
|
Service Code
|
HCPCS 28043
|
| Hospital Charge Code |
76100970
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$132.03 |
| Max. Negotiated Rate |
$3,045.87 |
| Rate for Payer: Aetna Commercial |
$389.82
|
| Rate for Payer: Ambetter Exchange |
$247.21
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$132.03
|
| Rate for Payer: Anthem Medicaid |
$151.32
|
| Rate for Payer: Buckeye Individual/Medicaid |
$247.21
|
| Rate for Payer: Buckeye Medicare Advantage |
$247.21
|
| Rate for Payer: CareSource Just4Me Medicare |
$296.65
|
| Rate for Payer: Cash Price |
$2,538.22
|
| Rate for Payer: Cash Price |
$2,538.22
|
| Rate for Payer: Cigna Commercial |
$463.59
|
| Rate for Payer: Healthspan PPO |
$432.59
|
| Rate for Payer: Humana Medicaid |
$151.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$330.03
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$247.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$247.21
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$154.35
|
| Rate for Payer: Molina Healthcare Passport |
$151.32
|
| Rate for Payer: Multiplan PHCS |
$3,045.87
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$321.37
|
| Rate for Payer: UHCCP Medicaid |
$138.63
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$152.83
|
| Rate for Payer: Wellcare Medicare Advantage |
$247.21
|
|
|
EXC FOOT/TOE TUM SC < 1.5 CM
|
Facility
|
IP
|
$5,076.45
|
|
|
Service Code
|
HCPCS 28043
|
| Hospital Charge Code |
76100970
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,522.93 |
| Max. Negotiated Rate |
$4,873.39 |
| Rate for Payer: Aetna Commercial |
$3,908.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,959.63
|
| Rate for Payer: Cash Price |
$2,538.22
|
| Rate for Payer: Cigna Commercial |
$4,213.45
|
| Rate for Payer: First Health Commercial |
$4,822.63
|
| Rate for Payer: Humana Commercial |
$4,314.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,162.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,746.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,522.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,467.28
|
| Rate for Payer: Ohio Health Group HMO |
$3,807.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,061.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,416.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,502.75
|
| Rate for Payer: PHCS Commercial |
$4,873.39
|
| Rate for Payer: United Healthcare All Payer |
$4,467.28
|
|
|
EXC FOOT/TOE TUM SC 1.5 CM/>
|
Facility
|
OP
|
$810.00
|
|
|
Service Code
|
HCPCS 28039
|
| Hospital Charge Code |
76100969
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$278.56 |
| Max. Negotiated Rate |
$3,702.27 |
| Rate for Payer: Aetna Commercial |
$623.70
|
| Rate for Payer: Anthem Medicaid |
$278.56
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,644.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$631.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,702.27
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,570.05
|
| Rate for Payer: Cash Price |
$405.00
|
| Rate for Payer: Cash Price |
$405.00
|
| Rate for Payer: Cigna Commercial |
$672.30
|
| Rate for Payer: First Health Commercial |
$769.50
|
| Rate for Payer: Humana Commercial |
$688.50
|
| Rate for Payer: Humana KY Medicaid |
$278.56
|
| Rate for Payer: Humana Medicare Advantage |
$2,644.48
|
| Rate for Payer: Kentucky WC Medicaid |
$281.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$664.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$597.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,173.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$284.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$712.80
|
| Rate for Payer: Ohio Health Group HMO |
$607.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$648.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$704.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$558.90
|
| Rate for Payer: PHCS Commercial |
$777.60
|
| Rate for Payer: United Healthcare All Payer |
$712.80
|
|
|
EXC FOOT/TOE TUM SC 1.5 CM/>
|
Professional
|
Both
|
$810.00
|
|
|
Service Code
|
HCPCS 28039
|
| Hospital Charge Code |
76100969
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$177.19 |
| Max. Negotiated Rate |
$824.93 |
| Rate for Payer: Aetna Commercial |
$519.64
|
| Rate for Payer: Ambetter Exchange |
$319.39
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$177.19
|
| Rate for Payer: Anthem Medicaid |
$342.75
|
| Rate for Payer: Buckeye Individual/Medicaid |
$319.39
|
| Rate for Payer: Buckeye Medicare Advantage |
$319.39
|
| Rate for Payer: CareSource Just4Me Medicare |
$383.27
|
| Rate for Payer: Cash Price |
$405.00
|
| Rate for Payer: Cash Price |
$405.00
|
| Rate for Payer: Cigna Commercial |
$824.93
|
| Rate for Payer: Healthspan PPO |
$510.10
|
| Rate for Payer: Humana Medicaid |
$342.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$422.58
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$319.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$319.39
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$349.61
|
| Rate for Payer: Molina Healthcare Passport |
$342.75
|
| Rate for Payer: Multiplan PHCS |
$486.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$415.21
|
| Rate for Payer: UHCCP Medicaid |
$186.05
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$346.18
|
| Rate for Payer: Wellcare Medicare Advantage |
$319.39
|
|
|
EXC FOOT/TOE TUM SC 1.5 CM/>
|
Facility
|
IP
|
$810.00
|
|
|
Service Code
|
HCPCS 28039
|
| Hospital Charge Code |
76100969
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$243.00 |
| Max. Negotiated Rate |
$777.60 |
| Rate for Payer: Aetna Commercial |
$623.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$631.80
|
| Rate for Payer: Cash Price |
$405.00
|
| Rate for Payer: Cigna Commercial |
$672.30
|
| Rate for Payer: First Health Commercial |
$769.50
|
| Rate for Payer: Humana Commercial |
$688.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$664.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$597.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$243.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$712.80
|
| Rate for Payer: Ohio Health Group HMO |
$607.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$648.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$704.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$558.90
|
| Rate for Payer: PHCS Commercial |
$777.60
|
| Rate for Payer: United Healthcare All Payer |
$712.80
|
|
|
EXC FOOT/TOE TUM SC 1.5 CM/(P
|
Professional
|
Both
|
$810.00
|
|
|
Service Code
|
HCPCS 28039
|
| Hospital Charge Code |
761P0969
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$177.19 |
| Max. Negotiated Rate |
$824.93 |
| Rate for Payer: Aetna Commercial |
$519.64
|
| Rate for Payer: Ambetter Exchange |
$319.39
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$177.19
|
| Rate for Payer: Anthem Medicaid |
$342.75
|
| Rate for Payer: Buckeye Individual/Medicaid |
$319.39
|
| Rate for Payer: Buckeye Medicare Advantage |
$319.39
|
| Rate for Payer: CareSource Just4Me Medicare |
$383.27
|
| Rate for Payer: Cash Price |
$405.00
|
| Rate for Payer: Cash Price |
$405.00
|
| Rate for Payer: Cigna Commercial |
$824.93
|
| Rate for Payer: Healthspan PPO |
$510.10
|
| Rate for Payer: Humana Medicaid |
$342.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$422.58
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$319.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$319.39
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$349.61
|
| Rate for Payer: Molina Healthcare Passport |
$342.75
|
| Rate for Payer: Multiplan PHCS |
$486.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$415.21
|
| Rate for Payer: UHCCP Medicaid |
$186.05
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$346.18
|
| Rate for Payer: Wellcare Medicare Advantage |
$319.39
|
|
|
EXC FOOT/TOE TUM SC < 1.5 C(P
|
Professional
|
Both
|
$940.00
|
|
|
Service Code
|
HCPCS 28043
|
| Hospital Charge Code |
761P0970
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$132.03 |
| Max. Negotiated Rate |
$564.00 |
| Rate for Payer: Aetna Commercial |
$389.82
|
| Rate for Payer: Ambetter Exchange |
$247.21
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$132.03
|
| Rate for Payer: Anthem Medicaid |
$151.32
|
| Rate for Payer: Buckeye Individual/Medicaid |
$247.21
|
| Rate for Payer: Buckeye Medicare Advantage |
$247.21
|
| Rate for Payer: CareSource Just4Me Medicare |
$296.65
|
| Rate for Payer: Cash Price |
$470.00
|
| Rate for Payer: Cash Price |
$470.00
|
| Rate for Payer: Cigna Commercial |
$463.59
|
| Rate for Payer: Healthspan PPO |
$432.59
|
| Rate for Payer: Humana Medicaid |
$151.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$330.03
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$247.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$247.21
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$154.35
|
| Rate for Payer: Molina Healthcare Passport |
$151.32
|
| Rate for Payer: Multiplan PHCS |
$564.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$321.37
|
| Rate for Payer: UHCCP Medicaid |
$138.63
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$152.83
|
| Rate for Payer: Wellcare Medicare Advantage |
$247.21
|
|
|
EXC FOOT/TOE TUM SC < 1.5 C(T
|
Facility
|
IP
|
$4,136.45
|
|
|
Service Code
|
HCPCS 28043
|
| Hospital Charge Code |
761T0970
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,240.93 |
| Max. Negotiated Rate |
$3,970.99 |
| Rate for Payer: Aetna Commercial |
$3,185.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,226.43
|
| Rate for Payer: Cash Price |
$2,068.22
|
| Rate for Payer: Cigna Commercial |
$3,433.25
|
| Rate for Payer: First Health Commercial |
$3,929.63
|
| Rate for Payer: Humana Commercial |
$3,515.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,391.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,052.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,240.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,640.08
|
| Rate for Payer: Ohio Health Group HMO |
$3,102.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,309.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,598.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,854.15
|
| Rate for Payer: PHCS Commercial |
$3,970.99
|
| Rate for Payer: United Healthcare All Payer |
$3,640.08
|
|
|
EXC FOOT/TOE TUM SC < 1.5 C(T
|
Facility
|
OP
|
$4,136.45
|
|
|
Service Code
|
HCPCS 28043
|
| Hospital Charge Code |
761T0970
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,422.53 |
| Max. Negotiated Rate |
$3,970.99 |
| Rate for Payer: Aetna Commercial |
$3,185.07
|
| Rate for Payer: Anthem Medicaid |
$1,422.53
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,497.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,226.43
|
| 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 |
$2,068.22
|
| Rate for Payer: Cash Price |
$2,068.22
|
| Rate for Payer: Cigna Commercial |
$3,433.25
|
| Rate for Payer: First Health Commercial |
$3,929.63
|
| Rate for Payer: Humana Commercial |
$3,515.98
|
| Rate for Payer: Humana KY Medicaid |
$1,422.53
|
| Rate for Payer: Humana Medicare Advantage |
$1,497.07
|
| Rate for Payer: Kentucky WC Medicaid |
$1,437.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,391.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,052.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,796.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,451.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,640.08
|
| Rate for Payer: Ohio Health Group HMO |
$3,102.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,309.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,598.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,854.15
|
| Rate for Payer: PHCS Commercial |
$3,970.99
|
| Rate for Payer: United Healthcare All Payer |
$3,640.08
|
|
|
EXC FOREARM LES SC > 3 CM
|
Facility
|
IP
|
$5,632.00
|
|
|
Service Code
|
HCPCS 25071
|
| Hospital Charge Code |
76100573
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,689.60 |
| Max. Negotiated Rate |
$5,406.72 |
| Rate for Payer: Aetna Commercial |
$4,336.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,392.96
|
| Rate for Payer: Cash Price |
$2,816.00
|
| Rate for Payer: Cigna Commercial |
$4,674.56
|
| Rate for Payer: First Health Commercial |
$5,350.40
|
| Rate for Payer: Humana Commercial |
$4,787.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,618.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,156.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,689.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,956.16
|
| Rate for Payer: Ohio Health Group HMO |
$4,224.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,505.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,899.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,886.08
|
| Rate for Payer: PHCS Commercial |
$5,406.72
|
| Rate for Payer: United Healthcare All Payer |
$4,956.16
|
|
|
EXC FOREARM LES SC > 3 CM
|
Facility
|
OP
|
$5,632.00
|
|
|
Service Code
|
HCPCS 25071
|
| Hospital Charge Code |
76100573
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,497.07 |
| Max. Negotiated Rate |
$5,406.72 |
| Rate for Payer: Aetna Commercial |
$4,336.64
|
| Rate for Payer: Anthem Medicaid |
$1,936.84
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,497.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,392.96
|
| 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 |
$2,816.00
|
| Rate for Payer: Cash Price |
$2,816.00
|
| Rate for Payer: Cigna Commercial |
$4,674.56
|
| Rate for Payer: First Health Commercial |
$5,350.40
|
| Rate for Payer: Humana Commercial |
$4,787.20
|
| Rate for Payer: Humana KY Medicaid |
$1,936.84
|
| Rate for Payer: Humana Medicare Advantage |
$1,497.07
|
| Rate for Payer: Kentucky WC Medicaid |
$1,956.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,618.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,156.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,796.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,975.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,956.16
|
| Rate for Payer: Ohio Health Group HMO |
$4,224.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,505.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,899.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,886.08
|
| Rate for Payer: PHCS Commercial |
$5,406.72
|
| Rate for Payer: United Healthcare All Payer |
$4,956.16
|
|
|
EXC FOREARM LES SC > 3 CM
|
Professional
|
Both
|
$5,632.00
|
|
|
Service Code
|
HCPCS 25071
|
| Hospital Charge Code |
76100573
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$306.72 |
| Max. Negotiated Rate |
$3,379.20 |
| Rate for Payer: Aetna Commercial |
$651.18
|
| Rate for Payer: Ambetter Exchange |
$405.69
|
| Rate for Payer: Anthem Medicaid |
$306.72
|
| Rate for Payer: Buckeye Individual/Medicaid |
$405.69
|
| Rate for Payer: Buckeye Medicare Advantage |
$405.69
|
| Rate for Payer: CareSource Just4Me Medicare |
$486.83
|
| Rate for Payer: Cash Price |
$2,816.00
|
| Rate for Payer: Cash Price |
$2,816.00
|
| Rate for Payer: Cigna Commercial |
$742.45
|
| Rate for Payer: Healthspan PPO |
$464.55
|
| Rate for Payer: Humana Medicaid |
$306.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$543.44
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$405.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$405.69
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$312.85
|
| Rate for Payer: Molina Healthcare Passport |
$306.72
|
| Rate for Payer: Multiplan PHCS |
$3,379.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$527.40
|
| Rate for Payer: UHCCP Medicaid |
$1,971.20
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$309.79
|
| Rate for Payer: Wellcare Medicare Advantage |
$405.69
|
|
|
EXC FOREARM LES SC > 3 CM(P
|
Professional
|
Both
|
$690.00
|
|
|
Service Code
|
HCPCS 25071
|
| Hospital Charge Code |
761P0573
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$241.50 |
| Max. Negotiated Rate |
$742.45 |
| Rate for Payer: Aetna Commercial |
$651.18
|
| Rate for Payer: Ambetter Exchange |
$405.69
|
| Rate for Payer: Anthem Medicaid |
$306.72
|
| Rate for Payer: Buckeye Individual/Medicaid |
$405.69
|
| Rate for Payer: Buckeye Medicare Advantage |
$405.69
|
| Rate for Payer: CareSource Just4Me Medicare |
$486.83
|
| Rate for Payer: Cash Price |
$345.00
|
| Rate for Payer: Cash Price |
$345.00
|
| Rate for Payer: Cigna Commercial |
$742.45
|
| Rate for Payer: Healthspan PPO |
$464.55
|
| Rate for Payer: Humana Medicaid |
$306.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$543.44
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$405.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$405.69
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$312.85
|
| Rate for Payer: Molina Healthcare Passport |
$306.72
|
| Rate for Payer: Multiplan PHCS |
$414.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$527.40
|
| Rate for Payer: UHCCP Medicaid |
$241.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$309.79
|
| Rate for Payer: Wellcare Medicare Advantage |
$405.69
|
|
|
EXC FOREARM LES SC > 3 CM(T
|
Facility
|
OP
|
$4,942.00
|
|
|
Service Code
|
HCPCS 25071
|
| Hospital Charge Code |
761T0573
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,497.07 |
| Max. Negotiated Rate |
$4,744.32 |
| Rate for Payer: Aetna Commercial |
$3,805.34
|
| Rate for Payer: Anthem Medicaid |
$1,699.55
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,497.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,854.76
|
| 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 |
$2,471.00
|
| Rate for Payer: Cash Price |
$2,471.00
|
| Rate for Payer: Cigna Commercial |
$4,101.86
|
| Rate for Payer: First Health Commercial |
$4,694.90
|
| Rate for Payer: Humana Commercial |
$4,200.70
|
| Rate for Payer: Humana KY Medicaid |
$1,699.55
|
| Rate for Payer: Humana Medicare Advantage |
$1,497.07
|
| Rate for Payer: Kentucky WC Medicaid |
$1,716.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,052.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,647.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,796.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,733.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,348.96
|
| Rate for Payer: Ohio Health Group HMO |
$3,706.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,953.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,299.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,409.98
|
| Rate for Payer: PHCS Commercial |
$4,744.32
|
| Rate for Payer: United Healthcare All Payer |
$4,348.96
|
|
