|
EXC LEG/ANKLE TUM DEP 5 CM/(P
|
Professional
|
Both
|
$1,600.00
|
|
|
Service Code
|
HCPCS 27634
|
| Hospital Charge Code |
761P0902
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$489.38 |
| Max. Negotiated Rate |
$1,181.31 |
| Rate for Payer: Aetna Commercial |
$1,035.39
|
| Rate for Payer: Ambetter Exchange |
$638.29
|
| Rate for Payer: Anthem Medicaid |
$489.38
|
| Rate for Payer: Buckeye Individual/Medicaid |
$638.29
|
| Rate for Payer: Buckeye Medicare Advantage |
$638.29
|
| Rate for Payer: CareSource Just4Me Medicare |
$765.95
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cigna Commercial |
$1,181.31
|
| Rate for Payer: Healthspan PPO |
$738.86
|
| Rate for Payer: Humana Medicaid |
$489.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$854.64
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$638.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$638.29
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$499.17
|
| Rate for Payer: Molina Healthcare Passport |
$489.38
|
| Rate for Payer: Multiplan PHCS |
$960.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$829.78
|
| Rate for Payer: UHCCP Medicaid |
$560.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$494.27
|
| Rate for Payer: Wellcare Medicare Advantage |
$638.29
|
|
|
EXC. LESIN OF TENDON SHEATH
|
Facility
|
OP
|
$800.00
|
|
|
Service Code
|
HCPCS 27630
|
| Hospital Charge Code |
76100900
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$275.12 |
| Max. Negotiated Rate |
$4,197.13 |
| Rate for Payer: Aetna Commercial |
$616.00
|
| Rate for Payer: Anthem Medicaid |
$275.12
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,997.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$624.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,197.13
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,047.23
|
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Cigna Commercial |
$664.00
|
| Rate for Payer: First Health Commercial |
$760.00
|
| Rate for Payer: Humana Commercial |
$680.00
|
| Rate for Payer: Humana KY Medicaid |
$275.12
|
| Rate for Payer: Humana Medicare Advantage |
$2,997.95
|
| Rate for Payer: Kentucky WC Medicaid |
$277.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$656.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$590.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,597.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$280.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$704.00
|
| Rate for Payer: Ohio Health Group HMO |
$600.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$640.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$696.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$552.00
|
| Rate for Payer: PHCS Commercial |
$768.00
|
| Rate for Payer: United Healthcare All Payer |
$704.00
|
|
|
EXC. LESIN OF TENDON SHEATH
|
Facility
|
IP
|
$800.00
|
|
|
Service Code
|
HCPCS 27630
|
| Hospital Charge Code |
76100900
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$240.00 |
| Max. Negotiated Rate |
$768.00 |
| Rate for Payer: Aetna Commercial |
$616.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$624.00
|
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Cigna Commercial |
$664.00
|
| Rate for Payer: First Health Commercial |
$760.00
|
| Rate for Payer: Humana Commercial |
$680.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$656.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$590.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$240.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$704.00
|
| Rate for Payer: Ohio Health Group HMO |
$600.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$640.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$696.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$552.00
|
| Rate for Payer: PHCS Commercial |
$768.00
|
| Rate for Payer: United Healthcare All Payer |
$704.00
|
|
|
EXC. LESIN OF TENDON SHEATH
|
Professional
|
Both
|
$800.00
|
|
|
Service Code
|
HCPCS 27630
|
| Hospital Charge Code |
76100900
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$184.11 |
| Max. Negotiated Rate |
$676.54 |
| Rate for Payer: Aetna Commercial |
$543.53
|
| Rate for Payer: Ambetter Exchange |
$342.05
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$184.11
|
| Rate for Payer: Anthem Medicaid |
$230.77
|
| Rate for Payer: Buckeye Individual/Medicaid |
$342.05
|
| Rate for Payer: Buckeye Medicare Advantage |
$342.05
|
| Rate for Payer: CareSource Just4Me Medicare |
$410.46
|
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Cigna Commercial |
$602.70
|
| Rate for Payer: Healthspan PPO |
$676.54
|
| Rate for Payer: Humana Medicaid |
$230.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$453.45
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$342.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$342.05
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$235.39
|
| Rate for Payer: Molina Healthcare Passport |
$230.77
|
| Rate for Payer: Multiplan PHCS |
$480.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$444.67
|
| Rate for Payer: UHCCP Medicaid |
$193.32
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$233.08
|
| Rate for Payer: Wellcare Medicare Advantage |
$342.05
|
|
|
EXC. LESIN OF TENDON SHEATH(P
|
Professional
|
Both
|
$800.00
|
|
|
Service Code
|
HCPCS 27630
|
| Hospital Charge Code |
761P0900
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$184.11 |
| Max. Negotiated Rate |
$676.54 |
| Rate for Payer: Aetna Commercial |
$543.53
|
| Rate for Payer: Ambetter Exchange |
$342.05
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$184.11
|
| Rate for Payer: Anthem Medicaid |
$230.77
|
| Rate for Payer: Buckeye Individual/Medicaid |
$342.05
|
| Rate for Payer: Buckeye Medicare Advantage |
$342.05
|
| Rate for Payer: CareSource Just4Me Medicare |
$410.46
|
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Cigna Commercial |
$602.70
|
| Rate for Payer: Healthspan PPO |
$676.54
|
| Rate for Payer: Humana Medicaid |
$230.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$453.45
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$342.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$342.05
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$235.39
|
| Rate for Payer: Molina Healthcare Passport |
$230.77
|
| Rate for Payer: Multiplan PHCS |
$480.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$444.67
|
| Rate for Payer: UHCCP Medicaid |
$193.32
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$233.08
|
| Rate for Payer: Wellcare Medicare Advantage |
$342.05
|
|
|
EXC LESION FLOOR OF MOUTH
|
Facility
|
OP
|
$6,428.72
|
|
|
Service Code
|
HCPCS 41116
|
| Hospital Charge Code |
76101659
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,210.84 |
| Max. Negotiated Rate |
$6,171.57 |
| Rate for Payer: Aetna Commercial |
$4,950.11
|
| Rate for Payer: Anthem Medicaid |
$2,210.84
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,996.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,014.40
|
| 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 |
$3,214.36
|
| Rate for Payer: Cash Price |
$3,214.36
|
| Rate for Payer: Cigna Commercial |
$5,335.84
|
| Rate for Payer: First Health Commercial |
$6,107.28
|
| Rate for Payer: Humana Commercial |
$5,464.41
|
| Rate for Payer: Humana KY Medicaid |
$2,210.84
|
| Rate for Payer: Humana Medicare Advantage |
$2,996.53
|
| Rate for Payer: Kentucky WC Medicaid |
$2,233.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,271.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,744.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,595.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,255.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,657.27
|
| Rate for Payer: Ohio Health Group HMO |
$4,821.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,142.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,592.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,435.82
|
| Rate for Payer: PHCS Commercial |
$6,171.57
|
| Rate for Payer: United Healthcare All Payer |
$5,657.27
|
|
|
EXC LESION FLOOR OF MOUTH
|
Facility
|
IP
|
$6,428.72
|
|
|
Service Code
|
HCPCS 41116
|
| Hospital Charge Code |
76101659
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,928.62 |
| Max. Negotiated Rate |
$6,171.57 |
| Rate for Payer: Aetna Commercial |
$4,950.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,014.40
|
| Rate for Payer: Cash Price |
$3,214.36
|
| Rate for Payer: Cigna Commercial |
$5,335.84
|
| Rate for Payer: First Health Commercial |
$6,107.28
|
| Rate for Payer: Humana Commercial |
$5,464.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,271.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,744.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,928.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,657.27
|
| Rate for Payer: Ohio Health Group HMO |
$4,821.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,142.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,592.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,435.82
|
| Rate for Payer: PHCS Commercial |
$6,171.57
|
| Rate for Payer: United Healthcare All Payer |
$5,657.27
|
|
|
EXC LESION FLOOR OF MOUTH
|
Professional
|
Both
|
$6,428.72
|
|
|
Service Code
|
HCPCS 41116
|
| Hospital Charge Code |
76101659
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$141.65 |
| Max. Negotiated Rate |
$3,857.23 |
| Rate for Payer: Aetna Commercial |
$309.36
|
| Rate for Payer: Ambetter Exchange |
$202.49
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$141.65
|
| Rate for Payer: Anthem Medicaid |
$142.60
|
| Rate for Payer: Buckeye Individual/Medicaid |
$202.49
|
| Rate for Payer: Buckeye Medicare Advantage |
$202.49
|
| Rate for Payer: CareSource Just4Me Medicare |
$242.99
|
| Rate for Payer: Cash Price |
$3,214.36
|
| Rate for Payer: Cash Price |
$3,214.36
|
| Rate for Payer: Cigna Commercial |
$407.56
|
| Rate for Payer: Healthspan PPO |
$369.67
|
| Rate for Payer: Humana Medicaid |
$142.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$279.92
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$202.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$202.49
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$145.45
|
| Rate for Payer: Molina Healthcare Passport |
$142.60
|
| Rate for Payer: Multiplan PHCS |
$3,857.23
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$263.24
|
| Rate for Payer: UHCCP Medicaid |
$148.73
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$144.03
|
| Rate for Payer: Wellcare Medicare Advantage |
$202.49
|
|
|
EXC LESION FLOOR OF MOUTH(P
|
Professional
|
Both
|
$800.00
|
|
|
Service Code
|
HCPCS 41116
|
| Hospital Charge Code |
761P1659
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$141.65 |
| Max. Negotiated Rate |
$480.00 |
| Rate for Payer: Aetna Commercial |
$309.36
|
| Rate for Payer: Ambetter Exchange |
$202.49
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$141.65
|
| Rate for Payer: Anthem Medicaid |
$142.60
|
| Rate for Payer: Buckeye Individual/Medicaid |
$202.49
|
| Rate for Payer: Buckeye Medicare Advantage |
$202.49
|
| Rate for Payer: CareSource Just4Me Medicare |
$242.99
|
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Cigna Commercial |
$407.56
|
| Rate for Payer: Healthspan PPO |
$369.67
|
| Rate for Payer: Humana Medicaid |
$142.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$279.92
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$202.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$202.49
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$145.45
|
| Rate for Payer: Molina Healthcare Passport |
$142.60
|
| Rate for Payer: Multiplan PHCS |
$480.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$263.24
|
| Rate for Payer: UHCCP Medicaid |
$148.73
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$144.03
|
| Rate for Payer: Wellcare Medicare Advantage |
$202.49
|
|
|
EXC LESION FLOOR OF MOUTH(T
|
Facility
|
IP
|
$5,628.72
|
|
|
Service Code
|
HCPCS 41116
|
| Hospital Charge Code |
761T1659
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,688.62 |
| Max. Negotiated Rate |
$5,403.57 |
| Rate for Payer: Aetna Commercial |
$4,334.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,390.40
|
| Rate for Payer: Cash Price |
$2,814.36
|
| Rate for Payer: Cigna Commercial |
$4,671.84
|
| Rate for Payer: First Health Commercial |
$5,347.28
|
| Rate for Payer: Humana Commercial |
$4,784.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,615.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,154.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,688.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,953.27
|
| Rate for Payer: Ohio Health Group HMO |
$4,221.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,502.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,896.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,883.82
|
| Rate for Payer: PHCS Commercial |
$5,403.57
|
| Rate for Payer: United Healthcare All Payer |
$4,953.27
|
|
|
EXC LESION FLOOR OF MOUTH(T
|
Facility
|
OP
|
$5,628.72
|
|
|
Service Code
|
HCPCS 41116
|
| Hospital Charge Code |
761T1659
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,935.72 |
| Max. Negotiated Rate |
$5,403.57 |
| Rate for Payer: Aetna Commercial |
$4,334.11
|
| Rate for Payer: Anthem Medicaid |
$1,935.72
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,996.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,390.40
|
| 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 |
$2,814.36
|
| Rate for Payer: Cash Price |
$2,814.36
|
| Rate for Payer: Cigna Commercial |
$4,671.84
|
| Rate for Payer: First Health Commercial |
$5,347.28
|
| Rate for Payer: Humana Commercial |
$4,784.41
|
| Rate for Payer: Humana KY Medicaid |
$1,935.72
|
| Rate for Payer: Humana Medicare Advantage |
$2,996.53
|
| Rate for Payer: Kentucky WC Medicaid |
$1,955.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,615.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,154.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,595.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,974.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,953.27
|
| Rate for Payer: Ohio Health Group HMO |
$4,221.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,502.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,896.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,883.82
|
| Rate for Payer: PHCS Commercial |
$5,403.57
|
| Rate for Payer: United Healthcare All Payer |
$4,953.27
|
|
|
EXC LESION OF PALATE UVULA
|
Facility
|
IP
|
$4,701.00
|
|
|
Service Code
|
HCPCS 42104
|
| Hospital Charge Code |
76101669
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,410.30 |
| Max. Negotiated Rate |
$4,512.96 |
| Rate for Payer: Aetna Commercial |
$3,619.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,666.78
|
| Rate for Payer: Cash Price |
$2,350.50
|
| Rate for Payer: Cigna Commercial |
$3,901.83
|
| Rate for Payer: First Health Commercial |
$4,465.95
|
| Rate for Payer: Humana Commercial |
$3,995.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,854.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,469.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,410.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,136.88
|
| Rate for Payer: Ohio Health Group HMO |
$3,525.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,760.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,089.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,243.69
|
| Rate for Payer: PHCS Commercial |
$4,512.96
|
| Rate for Payer: United Healthcare All Payer |
$4,136.88
|
|
|
EXC LESION OF PALATE UVULA
|
Professional
|
Both
|
$4,701.00
|
|
|
Service Code
|
HCPCS 42104
|
| Hospital Charge Code |
76101669
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$94.24 |
| Max. Negotiated Rate |
$2,820.60 |
| Rate for Payer: Aetna Commercial |
$195.54
|
| Rate for Payer: Ambetter Exchange |
$126.55
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$94.97
|
| Rate for Payer: Anthem Medicaid |
$94.24
|
| Rate for Payer: Buckeye Individual/Medicaid |
$126.55
|
| Rate for Payer: Buckeye Medicare Advantage |
$126.55
|
| Rate for Payer: CareSource Just4Me Medicare |
$151.86
|
| Rate for Payer: Cash Price |
$2,350.50
|
| Rate for Payer: Cash Price |
$2,350.50
|
| Rate for Payer: Cigna Commercial |
$255.75
|
| Rate for Payer: Healthspan PPO |
$239.37
|
| Rate for Payer: Humana Medicaid |
$94.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$176.81
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$126.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$126.55
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$96.12
|
| Rate for Payer: Molina Healthcare Passport |
$94.24
|
| Rate for Payer: Multiplan PHCS |
$2,820.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$164.51
|
| Rate for Payer: UHCCP Medicaid |
$99.72
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$95.18
|
| Rate for Payer: Wellcare Medicare Advantage |
$126.55
|
|
|
EXC LESION OF PALATE UVULA
|
Facility
|
OP
|
$4,701.00
|
|
|
Service Code
|
HCPCS 42104
|
| Hospital Charge Code |
76101669
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,616.67 |
| Max. Negotiated Rate |
$4,512.96 |
| Rate for Payer: Aetna Commercial |
$3,619.77
|
| Rate for Payer: Anthem Medicaid |
$1,616.67
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,996.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,666.78
|
| 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 |
$2,350.50
|
| Rate for Payer: Cash Price |
$2,350.50
|
| Rate for Payer: Cigna Commercial |
$3,901.83
|
| Rate for Payer: First Health Commercial |
$4,465.95
|
| Rate for Payer: Humana Commercial |
$3,995.85
|
| Rate for Payer: Humana KY Medicaid |
$1,616.67
|
| Rate for Payer: Humana Medicare Advantage |
$2,996.53
|
| Rate for Payer: Kentucky WC Medicaid |
$1,633.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,854.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,469.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,595.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,649.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,136.88
|
| Rate for Payer: Ohio Health Group HMO |
$3,525.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,760.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,089.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,243.69
|
| Rate for Payer: PHCS Commercial |
$4,512.96
|
| Rate for Payer: United Healthcare All Payer |
$4,136.88
|
|
|
EXC LESION OF PALATE UVULA(P
|
Professional
|
Both
|
$450.00
|
|
|
Service Code
|
HCPCS 42104
|
| Hospital Charge Code |
761P1669
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$94.24 |
| Max. Negotiated Rate |
$270.00 |
| Rate for Payer: Aetna Commercial |
$195.54
|
| Rate for Payer: Ambetter Exchange |
$126.55
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$94.97
|
| Rate for Payer: Anthem Medicaid |
$94.24
|
| Rate for Payer: Buckeye Individual/Medicaid |
$126.55
|
| Rate for Payer: Buckeye Medicare Advantage |
$126.55
|
| Rate for Payer: CareSource Just4Me Medicare |
$151.86
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cigna Commercial |
$255.75
|
| Rate for Payer: Healthspan PPO |
$239.37
|
| Rate for Payer: Humana Medicaid |
$94.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$176.81
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$126.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$126.55
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$96.12
|
| Rate for Payer: Molina Healthcare Passport |
$94.24
|
| Rate for Payer: Multiplan PHCS |
$270.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$164.51
|
| Rate for Payer: UHCCP Medicaid |
$99.72
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$95.18
|
| Rate for Payer: Wellcare Medicare Advantage |
$126.55
|
|
|
EXC LESION OF PALATE UVULA(T
|
Facility
|
OP
|
$4,251.00
|
|
|
Service Code
|
HCPCS 42104
|
| Hospital Charge Code |
761T1669
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,461.92 |
| Max. Negotiated Rate |
$4,195.14 |
| Rate for Payer: Aetna Commercial |
$3,273.27
|
| Rate for Payer: Anthem Medicaid |
$1,461.92
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,996.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,315.78
|
| 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 |
$2,125.50
|
| Rate for Payer: Cash Price |
$2,125.50
|
| Rate for Payer: Cigna Commercial |
$3,528.33
|
| Rate for Payer: First Health Commercial |
$4,038.45
|
| Rate for Payer: Humana Commercial |
$3,613.35
|
| Rate for Payer: Humana KY Medicaid |
$1,461.92
|
| Rate for Payer: Humana Medicare Advantage |
$2,996.53
|
| Rate for Payer: Kentucky WC Medicaid |
$1,476.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,485.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,137.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,595.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,491.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,740.88
|
| Rate for Payer: Ohio Health Group HMO |
$3,188.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,400.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,698.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,933.19
|
| Rate for Payer: PHCS Commercial |
$4,080.96
|
| Rate for Payer: United Healthcare All Payer |
$3,740.88
|
|
|
EXC LESION OF PALATE UVULA(T
|
Facility
|
IP
|
$4,251.00
|
|
|
Service Code
|
HCPCS 42104
|
| Hospital Charge Code |
761T1669
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,275.30 |
| Max. Negotiated Rate |
$4,080.96 |
| Rate for Payer: Aetna Commercial |
$3,273.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,315.78
|
| Rate for Payer: Cash Price |
$2,125.50
|
| Rate for Payer: Cigna Commercial |
$3,528.33
|
| Rate for Payer: First Health Commercial |
$4,038.45
|
| Rate for Payer: Humana Commercial |
$3,613.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,485.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,137.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,275.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,740.88
|
| Rate for Payer: Ohio Health Group HMO |
$3,188.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,400.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,698.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,933.19
|
| Rate for Payer: PHCS Commercial |
$4,080.96
|
| Rate for Payer: United Healthcare All Payer |
$3,740.88
|
|
|
EXC LESION OF TONGUE
|
Facility
|
IP
|
$5,386.00
|
|
|
Service Code
|
HCPCS 41110
|
| Hospital Charge Code |
76101654
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,615.80 |
| Max. Negotiated Rate |
$5,170.56 |
| Rate for Payer: Aetna Commercial |
$4,147.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,201.08
|
| Rate for Payer: Cash Price |
$2,693.00
|
| Rate for Payer: Cigna Commercial |
$4,470.38
|
| Rate for Payer: First Health Commercial |
$5,116.70
|
| Rate for Payer: Humana Commercial |
$4,578.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,416.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,974.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,615.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,739.68
|
| Rate for Payer: Ohio Health Group HMO |
$4,039.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,308.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,685.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,716.34
|
| Rate for Payer: PHCS Commercial |
$5,170.56
|
| Rate for Payer: United Healthcare All Payer |
$4,739.68
|
|
|
EXC LESION OF TONGUE
|
Professional
|
Both
|
$5,386.00
|
|
|
Service Code
|
HCPCS 41110
|
| Hospital Charge Code |
76101654
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$81.35 |
| Max. Negotiated Rate |
$3,231.60 |
| Rate for Payer: Aetna Commercial |
$185.89
|
| Rate for Payer: Ambetter Exchange |
$120.83
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$100.06
|
| Rate for Payer: Anthem Medicaid |
$81.35
|
| Rate for Payer: Buckeye Individual/Medicaid |
$120.83
|
| Rate for Payer: Buckeye Medicare Advantage |
$120.83
|
| Rate for Payer: CareSource Just4Me Medicare |
$145.00
|
| Rate for Payer: Cash Price |
$2,693.00
|
| Rate for Payer: Cash Price |
$2,693.00
|
| Rate for Payer: Cigna Commercial |
$266.57
|
| Rate for Payer: Healthspan PPO |
$238.46
|
| Rate for Payer: Humana Medicaid |
$81.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$168.98
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$120.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$120.83
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$82.98
|
| Rate for Payer: Molina Healthcare Passport |
$81.35
|
| Rate for Payer: Multiplan PHCS |
$3,231.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$157.08
|
| Rate for Payer: UHCCP Medicaid |
$105.06
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$82.16
|
| Rate for Payer: Wellcare Medicare Advantage |
$120.83
|
|
|
EXC LESION OF TONGUE
|
Facility
|
OP
|
$5,386.00
|
|
|
Service Code
|
HCPCS 41110
|
| Hospital Charge Code |
76101654
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,852.25 |
| Max. Negotiated Rate |
$5,170.56 |
| Rate for Payer: Aetna Commercial |
$4,147.22
|
| Rate for Payer: Anthem Medicaid |
$1,852.25
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,996.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,201.08
|
| 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 |
$2,693.00
|
| Rate for Payer: Cash Price |
$2,693.00
|
| Rate for Payer: Cigna Commercial |
$4,470.38
|
| Rate for Payer: First Health Commercial |
$5,116.70
|
| Rate for Payer: Humana Commercial |
$4,578.10
|
| Rate for Payer: Humana KY Medicaid |
$1,852.25
|
| Rate for Payer: Humana Medicare Advantage |
$2,996.53
|
| Rate for Payer: Kentucky WC Medicaid |
$1,871.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,416.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,974.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,595.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,889.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,739.68
|
| Rate for Payer: Ohio Health Group HMO |
$4,039.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,308.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,685.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,716.34
|
| Rate for Payer: PHCS Commercial |
$5,170.56
|
| Rate for Payer: United Healthcare All Payer |
$4,739.68
|
|
|
EXC LESION OF TONGUE(P
|
Professional
|
Both
|
$300.00
|
|
|
Service Code
|
HCPCS 41110
|
| Hospital Charge Code |
761P1654
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$81.35 |
| Max. Negotiated Rate |
$266.57 |
| Rate for Payer: Aetna Commercial |
$185.89
|
| Rate for Payer: Ambetter Exchange |
$120.83
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$100.06
|
| Rate for Payer: Anthem Medicaid |
$81.35
|
| Rate for Payer: Buckeye Individual/Medicaid |
$120.83
|
| Rate for Payer: Buckeye Medicare Advantage |
$120.83
|
| Rate for Payer: CareSource Just4Me Medicare |
$145.00
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cigna Commercial |
$266.57
|
| Rate for Payer: Healthspan PPO |
$238.46
|
| Rate for Payer: Humana Medicaid |
$81.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$168.98
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$120.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$120.83
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$82.98
|
| Rate for Payer: Molina Healthcare Passport |
$81.35
|
| Rate for Payer: Multiplan PHCS |
$180.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$157.08
|
| Rate for Payer: UHCCP Medicaid |
$105.06
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$82.16
|
| Rate for Payer: Wellcare Medicare Advantage |
$120.83
|
|
|
EXC LESION OF TONGUE(T
|
Facility
|
IP
|
$5,086.00
|
|
|
Service Code
|
HCPCS 41110
|
| Hospital Charge Code |
761T1654
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,525.80 |
| Max. Negotiated Rate |
$4,882.56 |
| Rate for Payer: Aetna Commercial |
$3,916.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,967.08
|
| Rate for Payer: Cash Price |
$2,543.00
|
| Rate for Payer: Cigna Commercial |
$4,221.38
|
| Rate for Payer: First Health Commercial |
$4,831.70
|
| Rate for Payer: Humana Commercial |
$4,323.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,170.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,753.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,525.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,475.68
|
| Rate for Payer: Ohio Health Group HMO |
$3,814.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,068.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,424.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,509.34
|
| Rate for Payer: PHCS Commercial |
$4,882.56
|
| Rate for Payer: United Healthcare All Payer |
$4,475.68
|
|
|
EXC LESION OF TONGUE(T
|
Facility
|
OP
|
$5,086.00
|
|
|
Service Code
|
HCPCS 41110
|
| Hospital Charge Code |
761T1654
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,749.08 |
| Max. Negotiated Rate |
$4,882.56 |
| Rate for Payer: Aetna Commercial |
$3,916.22
|
| Rate for Payer: Anthem Medicaid |
$1,749.08
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,996.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,967.08
|
| 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 |
$2,543.00
|
| Rate for Payer: Cash Price |
$2,543.00
|
| Rate for Payer: Cigna Commercial |
$4,221.38
|
| Rate for Payer: First Health Commercial |
$4,831.70
|
| Rate for Payer: Humana Commercial |
$4,323.10
|
| Rate for Payer: Humana KY Medicaid |
$1,749.08
|
| Rate for Payer: Humana Medicare Advantage |
$2,996.53
|
| Rate for Payer: Kentucky WC Medicaid |
$1,766.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,170.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,753.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,595.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,784.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,475.68
|
| Rate for Payer: Ohio Health Group HMO |
$3,814.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,068.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,424.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,509.34
|
| Rate for Payer: PHCS Commercial |
$4,882.56
|
| Rate for Payer: United Healthcare All Payer |
$4,475.68
|
|
|
EXC LES/TUMOR DENTOALVEOLAR
|
Facility
|
IP
|
$4,863.00
|
|
|
Service Code
|
HCPCS 41825
|
| Hospital Charge Code |
76101666
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,458.90 |
| Max. Negotiated Rate |
$4,668.48 |
| Rate for Payer: Aetna Commercial |
$3,744.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,793.14
|
| Rate for Payer: Cash Price |
$2,431.50
|
| Rate for Payer: Cigna Commercial |
$4,036.29
|
| Rate for Payer: First Health Commercial |
$4,619.85
|
| Rate for Payer: Humana Commercial |
$4,133.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,987.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,588.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,458.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,279.44
|
| Rate for Payer: Ohio Health Group HMO |
$3,647.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,890.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,230.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,355.47
|
| Rate for Payer: PHCS Commercial |
$4,668.48
|
| Rate for Payer: United Healthcare All Payer |
$4,279.44
|
|
|
EXC LES/TUMOR DENTOALVEOLAR
|
Professional
|
Both
|
$4,863.00
|
|
|
Service Code
|
HCPCS 41825
|
| Hospital Charge Code |
76101666
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$80.34 |
| Max. Negotiated Rate |
$2,917.80 |
| Rate for Payer: Aetna Commercial |
$178.52
|
| Rate for Payer: Ambetter Exchange |
$113.72
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$82.05
|
| Rate for Payer: Anthem Medicaid |
$80.34
|
| Rate for Payer: Buckeye Individual/Medicaid |
$113.72
|
| Rate for Payer: Buckeye Medicare Advantage |
$113.72
|
| Rate for Payer: CareSource Just4Me Medicare |
$136.46
|
| Rate for Payer: Cash Price |
$2,431.50
|
| Rate for Payer: Cash Price |
$2,431.50
|
| Rate for Payer: Cigna Commercial |
$263.09
|
| Rate for Payer: Healthspan PPO |
$233.60
|
| Rate for Payer: Humana Medicaid |
$80.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$158.49
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$113.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$113.72
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$81.95
|
| Rate for Payer: Molina Healthcare Passport |
$80.34
|
| Rate for Payer: Multiplan PHCS |
$2,917.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$147.84
|
| Rate for Payer: UHCCP Medicaid |
$86.15
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$81.14
|
| Rate for Payer: Wellcare Medicare Advantage |
$113.72
|
|
