|
EXCISE EXCESSIVE SKIN TISSUE
|
Facility
|
OP
|
$12,357.00
|
|
|
Service Code
|
HCPCS 15832
|
| Hospital Charge Code |
76100220
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,644.48 |
| Max. Negotiated Rate |
$11,862.72 |
| Rate for Payer: Aetna Commercial |
$9,514.89
|
| Rate for Payer: Anthem Medicaid |
$4,249.57
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,644.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,638.46
|
| 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 |
$6,178.50
|
| Rate for Payer: Cash Price |
$6,178.50
|
| Rate for Payer: Cigna Commercial |
$10,256.31
|
| Rate for Payer: First Health Commercial |
$11,739.15
|
| Rate for Payer: Humana Commercial |
$10,503.45
|
| Rate for Payer: Humana KY Medicaid |
$4,249.57
|
| Rate for Payer: Humana Medicare Advantage |
$2,644.48
|
| Rate for Payer: Kentucky WC Medicaid |
$4,292.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,132.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,119.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,173.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,334.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,874.16
|
| Rate for Payer: Ohio Health Group HMO |
$9,267.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,885.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,750.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,526.33
|
| Rate for Payer: PHCS Commercial |
$11,862.72
|
| Rate for Payer: United Healthcare All Payer |
$10,874.16
|
|
|
EXCISE EXCESSIVE SKIN TISSUE
|
Professional
|
Both
|
$12,357.00
|
|
|
Service Code
|
HCPCS 15832
|
| Hospital Charge Code |
76100220
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$576.57 |
| Max. Negotiated Rate |
$7,414.20 |
| Rate for Payer: Aetna Commercial |
$1,291.06
|
| Rate for Payer: Ambetter Exchange |
$876.98
|
| Rate for Payer: Anthem Medicaid |
$576.57
|
| Rate for Payer: Buckeye Individual/Medicaid |
$876.98
|
| Rate for Payer: Buckeye Medicare Advantage |
$876.98
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,052.38
|
| Rate for Payer: Cash Price |
$6,178.50
|
| Rate for Payer: Cash Price |
$6,178.50
|
| Rate for Payer: Cigna Commercial |
$1,226.94
|
| Rate for Payer: Healthspan PPO |
$1,032.32
|
| Rate for Payer: Humana Medicaid |
$576.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,155.59
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$876.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$876.98
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$588.10
|
| Rate for Payer: Molina Healthcare Passport |
$576.57
|
| Rate for Payer: Multiplan PHCS |
$7,414.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,140.07
|
| Rate for Payer: UHCCP Medicaid |
$4,324.95
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$582.34
|
| Rate for Payer: Wellcare Medicare Advantage |
$876.98
|
|
|
EXCISE EXCESSIVE SKIN TISSUE(P
|
Professional
|
Both
|
$2,200.00
|
|
|
Service Code
|
HCPCS 15832
|
| Hospital Charge Code |
761P0220
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$576.57 |
| Max. Negotiated Rate |
$1,320.00 |
| Rate for Payer: Aetna Commercial |
$1,291.06
|
| Rate for Payer: Ambetter Exchange |
$876.98
|
| Rate for Payer: Anthem Medicaid |
$576.57
|
| Rate for Payer: Buckeye Individual/Medicaid |
$876.98
|
| Rate for Payer: Buckeye Medicare Advantage |
$876.98
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,052.38
|
| Rate for Payer: Cash Price |
$1,100.00
|
| Rate for Payer: Cash Price |
$1,100.00
|
| Rate for Payer: Cigna Commercial |
$1,226.94
|
| Rate for Payer: Healthspan PPO |
$1,032.32
|
| Rate for Payer: Humana Medicaid |
$576.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,155.59
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$876.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$876.98
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$588.10
|
| Rate for Payer: Molina Healthcare Passport |
$576.57
|
| Rate for Payer: Multiplan PHCS |
$1,320.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,140.07
|
| Rate for Payer: UHCCP Medicaid |
$770.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$582.34
|
| Rate for Payer: Wellcare Medicare Advantage |
$876.98
|
|
|
EXCISE EXCESSIVE SKIN TISSUE(T
|
Facility
|
OP
|
$10,157.00
|
|
|
Service Code
|
HCPCS 15832
|
| Hospital Charge Code |
761T0220
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,644.48 |
| Max. Negotiated Rate |
$9,750.72 |
| Rate for Payer: Aetna Commercial |
$7,820.89
|
| Rate for Payer: Anthem Medicaid |
$3,492.99
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,644.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,922.46
|
| 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 |
$5,078.50
|
| Rate for Payer: Cash Price |
$5,078.50
|
| Rate for Payer: Cigna Commercial |
$8,430.31
|
| Rate for Payer: First Health Commercial |
$9,649.15
|
| Rate for Payer: Humana Commercial |
$8,633.45
|
| Rate for Payer: Humana KY Medicaid |
$3,492.99
|
| Rate for Payer: Humana Medicare Advantage |
$2,644.48
|
| Rate for Payer: Kentucky WC Medicaid |
$3,528.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,328.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,495.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,173.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,563.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,938.16
|
| Rate for Payer: Ohio Health Group HMO |
$7,617.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,125.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,836.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,008.33
|
| Rate for Payer: PHCS Commercial |
$9,750.72
|
| Rate for Payer: United Healthcare All Payer |
$8,938.16
|
|
|
EXCISE EXCESSIVE SKIN TISSUE(T
|
Facility
|
IP
|
$10,157.00
|
|
|
Service Code
|
HCPCS 15832
|
| Hospital Charge Code |
761T0220
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$3,047.10 |
| Max. Negotiated Rate |
$9,750.72 |
| Rate for Payer: Aetna Commercial |
$7,820.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,922.46
|
| Rate for Payer: Cash Price |
$5,078.50
|
| Rate for Payer: Cigna Commercial |
$8,430.31
|
| Rate for Payer: First Health Commercial |
$9,649.15
|
| Rate for Payer: Humana Commercial |
$8,633.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,328.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,495.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,047.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,938.16
|
| Rate for Payer: Ohio Health Group HMO |
$7,617.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,125.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,836.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,008.33
|
| Rate for Payer: PHCS Commercial |
$9,750.72
|
| Rate for Payer: United Healthcare All Payer |
$8,938.16
|
|
|
EXCISE EXCESS SKIN & TISSUE
|
Facility
|
IP
|
$8,201.83
|
|
|
Service Code
|
HCPCS 15839
|
| Hospital Charge Code |
76100223
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,460.55 |
| Max. Negotiated Rate |
$7,873.76 |
| Rate for Payer: Aetna Commercial |
$6,315.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,397.43
|
| Rate for Payer: Cash Price |
$4,100.92
|
| Rate for Payer: Cigna Commercial |
$6,807.52
|
| Rate for Payer: First Health Commercial |
$7,791.74
|
| Rate for Payer: Humana Commercial |
$6,971.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,725.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,052.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,460.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,217.61
|
| Rate for Payer: Ohio Health Group HMO |
$6,151.37
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,561.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,135.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,659.26
|
| Rate for Payer: PHCS Commercial |
$7,873.76
|
| Rate for Payer: United Healthcare All Payer |
$7,217.61
|
|
|
EXCISE EXCESS SKIN & TISSUE
|
Professional
|
Both
|
$8,201.83
|
|
|
Service Code
|
HCPCS 15839
|
| Hospital Charge Code |
76100223
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$338.37 |
| Max. Negotiated Rate |
$4,921.10 |
| Rate for Payer: Aetna Commercial |
$1,043.35
|
| Rate for Payer: Ambetter Exchange |
$699.02
|
| Rate for Payer: Anthem Medicaid |
$338.37
|
| Rate for Payer: Buckeye Individual/Medicaid |
$699.02
|
| Rate for Payer: Buckeye Medicare Advantage |
$699.02
|
| Rate for Payer: CareSource Just4Me Medicare |
$838.82
|
| Rate for Payer: Cash Price |
$4,100.92
|
| Rate for Payer: Cash Price |
$4,100.92
|
| Rate for Payer: Cigna Commercial |
$967.73
|
| Rate for Payer: Healthspan PPO |
$963.92
|
| Rate for Payer: Humana Medicaid |
$338.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$907.66
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$699.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$699.02
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$345.14
|
| Rate for Payer: Molina Healthcare Passport |
$338.37
|
| Rate for Payer: Multiplan PHCS |
$4,921.10
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$908.73
|
| Rate for Payer: UHCCP Medicaid |
$2,870.64
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$341.75
|
| Rate for Payer: Wellcare Medicare Advantage |
$699.02
|
|
|
EXCISE EXCESS SKIN & TISSUE
|
Facility
|
OP
|
$8,201.83
|
|
|
Service Code
|
HCPCS 15839
|
| Hospital Charge Code |
76100223
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,644.48 |
| Max. Negotiated Rate |
$7,873.76 |
| Rate for Payer: Aetna Commercial |
$6,315.41
|
| Rate for Payer: Anthem Medicaid |
$2,820.61
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,644.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,397.43
|
| 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 |
$4,100.92
|
| Rate for Payer: Cash Price |
$4,100.92
|
| Rate for Payer: Cigna Commercial |
$6,807.52
|
| Rate for Payer: First Health Commercial |
$7,791.74
|
| Rate for Payer: Humana Commercial |
$6,971.56
|
| Rate for Payer: Humana KY Medicaid |
$2,820.61
|
| Rate for Payer: Humana Medicare Advantage |
$2,644.48
|
| Rate for Payer: Kentucky WC Medicaid |
$2,849.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,725.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,052.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,173.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,877.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,217.61
|
| Rate for Payer: Ohio Health Group HMO |
$6,151.37
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,561.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,135.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,659.26
|
| Rate for Payer: PHCS Commercial |
$7,873.76
|
| Rate for Payer: United Healthcare All Payer |
$7,217.61
|
|
|
EXCISE EXCESS SKIN & TISSUE(P
|
Professional
|
Both
|
$2,000.00
|
|
|
Service Code
|
HCPCS 15839
|
| Hospital Charge Code |
761P0223
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$338.37 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$1,043.35
|
| Rate for Payer: Ambetter Exchange |
$699.02
|
| Rate for Payer: Anthem Medicaid |
$338.37
|
| Rate for Payer: Buckeye Individual/Medicaid |
$699.02
|
| Rate for Payer: Buckeye Medicare Advantage |
$699.02
|
| Rate for Payer: CareSource Just4Me Medicare |
$838.82
|
| Rate for Payer: Cash Price |
$1,000.00
|
| Rate for Payer: Cash Price |
$1,000.00
|
| Rate for Payer: Cigna Commercial |
$967.73
|
| Rate for Payer: Healthspan PPO |
$963.92
|
| Rate for Payer: Humana Medicaid |
$338.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$907.66
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$699.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$699.02
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$345.14
|
| Rate for Payer: Molina Healthcare Passport |
$338.37
|
| Rate for Payer: Multiplan PHCS |
$1,200.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$908.73
|
| Rate for Payer: UHCCP Medicaid |
$700.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$341.75
|
| Rate for Payer: Wellcare Medicare Advantage |
$699.02
|
|
|
EXCISE EXCESS SKIN & TISSUE(T
|
Facility
|
IP
|
$6,201.83
|
|
|
Service Code
|
HCPCS 15839
|
| Hospital Charge Code |
761T0223
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,860.55 |
| Max. Negotiated Rate |
$5,953.76 |
| Rate for Payer: Aetna Commercial |
$4,775.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,837.43
|
| Rate for Payer: Cash Price |
$3,100.92
|
| Rate for Payer: Cigna Commercial |
$5,147.52
|
| Rate for Payer: First Health Commercial |
$5,891.74
|
| Rate for Payer: Humana Commercial |
$5,271.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,085.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,576.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,860.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,457.61
|
| Rate for Payer: Ohio Health Group HMO |
$4,651.37
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,961.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,395.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,279.26
|
| Rate for Payer: PHCS Commercial |
$5,953.76
|
| Rate for Payer: United Healthcare All Payer |
$5,457.61
|
|
|
EXCISE EXCESS SKIN & TISSUE(T
|
Facility
|
OP
|
$6,201.83
|
|
|
Service Code
|
HCPCS 15839
|
| Hospital Charge Code |
761T0223
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,132.81 |
| Max. Negotiated Rate |
$5,953.76 |
| Rate for Payer: Aetna Commercial |
$4,775.41
|
| Rate for Payer: Anthem Medicaid |
$2,132.81
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,644.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,837.43
|
| 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 |
$3,100.92
|
| Rate for Payer: Cash Price |
$3,100.92
|
| Rate for Payer: Cigna Commercial |
$5,147.52
|
| Rate for Payer: First Health Commercial |
$5,891.74
|
| Rate for Payer: Humana Commercial |
$5,271.56
|
| Rate for Payer: Humana KY Medicaid |
$2,132.81
|
| Rate for Payer: Humana Medicare Advantage |
$2,644.48
|
| Rate for Payer: Kentucky WC Medicaid |
$2,154.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,085.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,576.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,173.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,175.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,457.61
|
| Rate for Payer: Ohio Health Group HMO |
$4,651.37
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,961.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,395.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,279.26
|
| Rate for Payer: PHCS Commercial |
$5,953.76
|
| Rate for Payer: United Healthcare All Payer |
$5,457.61
|
|
|
EXCISE FOOT TENDON SHEATH
|
Professional
|
Both
|
$735.00
|
|
|
Service Code
|
HCPCS 28086
|
| Hospital Charge Code |
76102720
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$181.86 |
| Max. Negotiated Rate |
$670.00 |
| Rate for Payer: Aetna Commercial |
$543.27
|
| Rate for Payer: Ambetter Exchange |
$329.60
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$181.86
|
| Rate for Payer: Anthem Medicaid |
$227.49
|
| Rate for Payer: Buckeye Individual/Medicaid |
$329.60
|
| Rate for Payer: Buckeye Medicare Advantage |
$329.60
|
| Rate for Payer: CareSource Just4Me Medicare |
$395.52
|
| Rate for Payer: Cash Price |
$367.50
|
| Rate for Payer: Cash Price |
$367.50
|
| Rate for Payer: Cigna Commercial |
$616.99
|
| Rate for Payer: Healthspan PPO |
$670.00
|
| Rate for Payer: Humana Medicaid |
$227.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$446.22
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$329.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$329.60
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$232.04
|
| Rate for Payer: Molina Healthcare Passport |
$227.49
|
| Rate for Payer: Multiplan PHCS |
$441.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$428.48
|
| Rate for Payer: UHCCP Medicaid |
$190.95
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$229.76
|
| Rate for Payer: Wellcare Medicare Advantage |
$329.60
|
|
|
EXCISE LESION TESTIS
|
Professional
|
Both
|
$1,265.00
|
|
|
Service Code
|
HCPCS 54512
|
| Hospital Charge Code |
76103007
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$385.12 |
| Max. Negotiated Rate |
$872.25 |
| Rate for Payer: Aetna Commercial |
$872.25
|
| Rate for Payer: Ambetter Exchange |
$510.84
|
| Rate for Payer: Anthem Medicaid |
$385.12
|
| Rate for Payer: Buckeye Individual/Medicaid |
$510.84
|
| Rate for Payer: Buckeye Medicare Advantage |
$510.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$613.01
|
| Rate for Payer: Cash Price |
$632.50
|
| Rate for Payer: Cash Price |
$632.50
|
| Rate for Payer: Cigna Commercial |
$777.79
|
| Rate for Payer: Healthspan PPO |
$844.56
|
| Rate for Payer: Humana Medicaid |
$385.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$730.70
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$510.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$510.84
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$392.82
|
| Rate for Payer: Molina Healthcare Passport |
$385.12
|
| Rate for Payer: Multiplan PHCS |
$759.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$664.09
|
| Rate for Payer: UHCCP Medicaid |
$442.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$388.97
|
| Rate for Payer: Wellcare Medicare Advantage |
$510.84
|
|
|
EXCISE LWR JAW CYST W/REPAI(P
|
Professional
|
Both
|
$3,235.00
|
|
|
Service Code
|
HCPCS 21047
|
| Hospital Charge Code |
761P0370
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$833.04 |
| Max. Negotiated Rate |
$2,110.05 |
| Rate for Payer: Aetna Commercial |
$1,907.63
|
| Rate for Payer: Ambetter Exchange |
$1,145.43
|
| Rate for Payer: Anthem Medicaid |
$833.04
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,145.43
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,145.43
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,374.52
|
| Rate for Payer: Cash Price |
$1,617.50
|
| Rate for Payer: Cash Price |
$1,617.50
|
| Rate for Payer: Cigna Commercial |
$2,110.05
|
| Rate for Payer: Healthspan PPO |
$1,727.91
|
| Rate for Payer: Humana Medicaid |
$833.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,621.26
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1,145.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,145.43
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$849.70
|
| Rate for Payer: Molina Healthcare Passport |
$833.04
|
| Rate for Payer: Multiplan PHCS |
$1,941.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,489.06
|
| Rate for Payer: UHCCP Medicaid |
$1,132.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$841.37
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,145.43
|
|
|
EXCISE LWR JAW CYST W/REPAIR
|
Facility
|
OP
|
$3,235.00
|
|
|
Service Code
|
HCPCS 21047
|
| Hospital Charge Code |
76100370
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,112.52 |
| Max. Negotiated Rate |
$7,652.33 |
| Rate for Payer: Aetna Commercial |
$2,490.95
|
| Rate for Payer: Anthem Medicaid |
$1,112.52
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5,465.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,523.30
|
| 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 |
$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 |
$5,465.95
|
| 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 |
$6,559.14
|
| 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
|
|
|
EXCISE LWR JAW CYST W/REPAIR
|
Professional
|
Both
|
$3,235.00
|
|
|
Service Code
|
HCPCS 21047
|
| Hospital Charge Code |
76100370
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$833.04 |
| Max. Negotiated Rate |
$2,110.05 |
| Rate for Payer: Aetna Commercial |
$1,907.63
|
| Rate for Payer: Ambetter Exchange |
$1,145.43
|
| Rate for Payer: Anthem Medicaid |
$833.04
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,145.43
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,145.43
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,374.52
|
| Rate for Payer: Cash Price |
$1,617.50
|
| Rate for Payer: Cash Price |
$1,617.50
|
| Rate for Payer: Cigna Commercial |
$2,110.05
|
| Rate for Payer: Healthspan PPO |
$1,727.91
|
| Rate for Payer: Humana Medicaid |
$833.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,621.26
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1,145.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,145.43
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$849.70
|
| Rate for Payer: Molina Healthcare Passport |
$833.04
|
| Rate for Payer: Multiplan PHCS |
$1,941.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,489.06
|
| Rate for Payer: UHCCP Medicaid |
$1,132.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$841.37
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,145.43
|
|
|
EXCISE LWR JAW CYST W/REPAIR
|
Facility
|
IP
|
$3,235.00
|
|
|
Service Code
|
HCPCS 21047
|
| Hospital Charge Code |
76100370
|
|
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
|
|
|
EXCISE ORAL MUCOSA FOR GRAF(P
|
Professional
|
Both
|
$1,010.00
|
|
|
Service Code
|
HCPCS 40818
|
| Hospital Charge Code |
761P1639
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$131.53 |
| Max. Negotiated Rate |
$606.00 |
| Rate for Payer: Aetna Commercial |
$378.58
|
| Rate for Payer: Ambetter Exchange |
$245.23
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$150.50
|
| Rate for Payer: Anthem Medicaid |
$131.53
|
| Rate for Payer: Buckeye Individual/Medicaid |
$245.23
|
| Rate for Payer: Buckeye Medicare Advantage |
$245.23
|
| Rate for Payer: CareSource Just4Me Medicare |
$294.28
|
| Rate for Payer: Cash Price |
$505.00
|
| Rate for Payer: Cash Price |
$505.00
|
| Rate for Payer: Cigna Commercial |
$381.86
|
| Rate for Payer: Healthspan PPO |
$401.85
|
| Rate for Payer: Humana Medicaid |
$131.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$342.06
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$245.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$245.23
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$134.16
|
| Rate for Payer: Molina Healthcare Passport |
$131.53
|
| Rate for Payer: Multiplan PHCS |
$606.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$318.80
|
| Rate for Payer: UHCCP Medicaid |
$158.03
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$132.85
|
| Rate for Payer: Wellcare Medicare Advantage |
$245.23
|
|
|
EXCISE ORAL MUCOSA FOR GRAFT
|
Facility
|
OP
|
$1,010.00
|
|
|
Service Code
|
HCPCS 40818
|
| Hospital Charge Code |
76101639
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$347.34 |
| Max. Negotiated Rate |
$969.60 |
| Rate for Payer: Aetna Commercial |
$777.70
|
| Rate for Payer: Anthem Medicaid |
$347.34
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$470.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$787.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$658.76
|
| Rate for Payer: CareSource Just4Me Medicare |
$635.23
|
| Rate for Payer: Cash Price |
$505.00
|
| Rate for Payer: Cash Price |
$505.00
|
| Rate for Payer: Cigna Commercial |
$838.30
|
| Rate for Payer: First Health Commercial |
$959.50
|
| Rate for Payer: Humana Commercial |
$858.50
|
| Rate for Payer: Humana KY Medicaid |
$347.34
|
| Rate for Payer: Humana Medicare Advantage |
$470.54
|
| Rate for Payer: Kentucky WC Medicaid |
$350.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$828.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$745.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$564.65
|
| Rate for Payer: Molina Healthcare Medicaid |
$354.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$888.80
|
| Rate for Payer: Ohio Health Group HMO |
$757.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$808.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$878.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$696.90
|
| Rate for Payer: PHCS Commercial |
$969.60
|
| Rate for Payer: United Healthcare All Payer |
$888.80
|
|
|
EXCISE ORAL MUCOSA FOR GRAFT
|
Facility
|
IP
|
$1,010.00
|
|
|
Service Code
|
HCPCS 40818
|
| Hospital Charge Code |
76101639
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$303.00 |
| Max. Negotiated Rate |
$969.60 |
| Rate for Payer: Aetna Commercial |
$777.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$787.80
|
| Rate for Payer: Cash Price |
$505.00
|
| Rate for Payer: Cigna Commercial |
$838.30
|
| Rate for Payer: First Health Commercial |
$959.50
|
| Rate for Payer: Humana Commercial |
$858.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$828.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$745.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$303.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$888.80
|
| Rate for Payer: Ohio Health Group HMO |
$757.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$808.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$878.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$696.90
|
| Rate for Payer: PHCS Commercial |
$969.60
|
| Rate for Payer: United Healthcare All Payer |
$888.80
|
|
|
EXCISE ORAL MUCOSA FOR GRAFT
|
Professional
|
Both
|
$1,010.00
|
|
|
Service Code
|
HCPCS 40818
|
| Hospital Charge Code |
76101639
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$131.53 |
| Max. Negotiated Rate |
$606.00 |
| Rate for Payer: Aetna Commercial |
$378.58
|
| Rate for Payer: Ambetter Exchange |
$245.23
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$150.50
|
| Rate for Payer: Anthem Medicaid |
$131.53
|
| Rate for Payer: Buckeye Individual/Medicaid |
$245.23
|
| Rate for Payer: Buckeye Medicare Advantage |
$245.23
|
| Rate for Payer: CareSource Just4Me Medicare |
$294.28
|
| Rate for Payer: Cash Price |
$505.00
|
| Rate for Payer: Cash Price |
$505.00
|
| Rate for Payer: Cigna Commercial |
$381.86
|
| Rate for Payer: Healthspan PPO |
$401.85
|
| Rate for Payer: Humana Medicaid |
$131.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$342.06
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$245.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$245.23
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$134.16
|
| Rate for Payer: Molina Healthcare Passport |
$131.53
|
| Rate for Payer: Multiplan PHCS |
$606.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$318.80
|
| Rate for Payer: UHCCP Medicaid |
$158.03
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$132.85
|
| Rate for Payer: Wellcare Medicare Advantage |
$245.23
|
|
|
EXCISE/REPAIR MOUTH LESION
|
Facility
|
IP
|
$1,030.00
|
|
|
Service Code
|
HCPCS 40814
|
| Hospital Charge Code |
76101637
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$309.00 |
| Max. Negotiated Rate |
$988.80 |
| Rate for Payer: Aetna Commercial |
$793.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$803.40
|
| Rate for Payer: Cash Price |
$515.00
|
| Rate for Payer: Cigna Commercial |
$854.90
|
| Rate for Payer: First Health Commercial |
$978.50
|
| Rate for Payer: Humana Commercial |
$875.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$844.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$760.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$309.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$906.40
|
| Rate for Payer: Ohio Health Group HMO |
$772.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$824.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$896.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$710.70
|
| Rate for Payer: PHCS Commercial |
$988.80
|
| Rate for Payer: United Healthcare All Payer |
$906.40
|
|
|
EXCISE/REPAIR MOUTH LESION
|
Facility
|
OP
|
$1,030.00
|
|
|
Service Code
|
HCPCS 40814
|
| Hospital Charge Code |
76101637
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$354.22 |
| Max. Negotiated Rate |
$4,195.14 |
| Rate for Payer: Aetna Commercial |
$793.10
|
| Rate for Payer: Anthem Medicaid |
$354.22
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,996.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$803.40
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,195.14
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,045.32
|
| Rate for Payer: Cash Price |
$515.00
|
| Rate for Payer: Cash Price |
$515.00
|
| Rate for Payer: Cigna Commercial |
$854.90
|
| Rate for Payer: First Health Commercial |
$978.50
|
| Rate for Payer: Humana Commercial |
$875.50
|
| Rate for Payer: Humana KY Medicaid |
$354.22
|
| Rate for Payer: Humana Medicare Advantage |
$2,996.53
|
| Rate for Payer: Kentucky WC Medicaid |
$357.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$844.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$760.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,595.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$361.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$906.40
|
| Rate for Payer: Ohio Health Group HMO |
$772.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$824.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$896.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$710.70
|
| Rate for Payer: PHCS Commercial |
$988.80
|
| Rate for Payer: United Healthcare All Payer |
$906.40
|
|
|
EXCISE/REPAIR MOUTH LESION
|
Professional
|
Both
|
$1,030.00
|
|
|
Service Code
|
HCPCS 40814
|
| Hospital Charge Code |
76101637
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$188.87 |
| Max. Negotiated Rate |
$618.00 |
| Rate for Payer: Aetna Commercial |
$430.67
|
| Rate for Payer: Ambetter Exchange |
$265.98
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$188.87
|
| Rate for Payer: Anthem Medicaid |
$190.36
|
| Rate for Payer: Buckeye Individual/Medicaid |
$265.98
|
| Rate for Payer: Buckeye Medicare Advantage |
$265.98
|
| Rate for Payer: CareSource Just4Me Medicare |
$319.18
|
| Rate for Payer: Cash Price |
$515.00
|
| Rate for Payer: Cash Price |
$515.00
|
| Rate for Payer: Cigna Commercial |
$500.77
|
| Rate for Payer: Healthspan PPO |
$440.82
|
| Rate for Payer: Humana Medicaid |
$190.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$384.93
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$265.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$265.98
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$194.17
|
| Rate for Payer: Molina Healthcare Passport |
$190.36
|
| Rate for Payer: Multiplan PHCS |
$618.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$345.77
|
| Rate for Payer: UHCCP Medicaid |
$198.31
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$192.26
|
| Rate for Payer: Wellcare Medicare Advantage |
$265.98
|
|
|
EXCISE/REPAIR MOUTH LESION(P
|
Professional
|
Both
|
$1,030.00
|
|
|
Service Code
|
HCPCS 40814
|
| Hospital Charge Code |
761P1637
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$188.87 |
| Max. Negotiated Rate |
$618.00 |
| Rate for Payer: Aetna Commercial |
$430.67
|
| Rate for Payer: Ambetter Exchange |
$265.98
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$188.87
|
| Rate for Payer: Anthem Medicaid |
$190.36
|
| Rate for Payer: Buckeye Individual/Medicaid |
$265.98
|
| Rate for Payer: Buckeye Medicare Advantage |
$265.98
|
| Rate for Payer: CareSource Just4Me Medicare |
$319.18
|
| Rate for Payer: Cash Price |
$515.00
|
| Rate for Payer: Cash Price |
$515.00
|
| Rate for Payer: Cigna Commercial |
$500.77
|
| Rate for Payer: Healthspan PPO |
$440.82
|
| Rate for Payer: Humana Medicaid |
$190.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$384.93
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$265.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$265.98
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$194.17
|
| Rate for Payer: Molina Healthcare Passport |
$190.36
|
| Rate for Payer: Multiplan PHCS |
$618.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$345.77
|
| Rate for Payer: UHCCP Medicaid |
$198.31
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$192.26
|
| Rate for Payer: Wellcare Medicare Advantage |
$265.98
|
|
