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    Gross Charge: $0

    Cash Price: $0

    Billing Code: #0

    De-Identified (low rate): $830

    De-Identified (high rate): $960

    AETNA rate: $0

    Gross Charge: $0

    Cash Price: $0

    Billing Code: #0

    De-Identified (low rate): $960

    De-Identified (high rate): $960

    AETNA rate: $0

    Gross Charge: $2,200.00

    Cash Price: $2,200.00

    Billing Code: #0

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    AETNA rate: $0

    Gross Charge: $2,200.00

    Cash Price: $2,200.00

    Billing Code: #126

    De-Identified (low rate): $690

    De-Identified (high rate): $1,160.00

    AETNA rate: $771

    Gross Charge: $2,200.00

    Cash Price: $2,200.00

    Billing Code: #124

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    AETNA rate: $0

    Gross Charge: $2,200.00

    Cash Price: $2,200.00

    Billing Code: #124

    De-Identified (low rate): $650

    De-Identified (high rate): $1,160.10

    AETNA rate: $857

    Gross Charge: $2,200.00

    Cash Price: $2,200.00

    Billing Code: #124

    De-Identified (low rate): $110

    De-Identified (high rate): $110

    AETNA rate: $0

    Gross Charge: $2,200.00

    Cash Price: $2,200.00

    Billing Code: #124

    De-Identified (low rate): $650

    De-Identified (high rate): $1,160.10

    AETNA rate: $857

    Gross Charge: $2,200.00

    Cash Price: $2,200.00

    Billing Code: #128

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    AETNA rate: $0

    Gross Charge: $2,200.00

    Cash Price: $2,200.00

    Billing Code: #124

    De-Identified (low rate): $650

    De-Identified (high rate): $1,160.10

    AETNA rate: $857

    Gross Charge: $2,200.00

    Cash Price: $2,200.00

    Billing Code: #128

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    AETNA rate: $0

    Gross Charge: $2,200.00

    Cash Price: $2,200.00

    Billing Code: #128

    De-Identified (low rate): $538

    De-Identified (high rate): $1,160.10

    AETNA rate: $788

    Gross Charge: $0

    Cash Price: $0

    Billing Code: #0

    De-Identified (low rate): $830

    De-Identified (high rate): $960

    AETNA BETTER rate: $0

    Gross Charge: $0

    Cash Price: $0

    Billing Code: #0

    De-Identified (low rate): $960

    De-Identified (high rate): $960

    AETNA BETTER rate: $0

    Gross Charge: $2,200.00

    Cash Price: $2,200.00

    Billing Code: #126

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    AETNA BETTER rate: $0

    Gross Charge: $2,200.00

    Cash Price: $2,200.00

    Billing Code: #126

    De-Identified (low rate): $690

    De-Identified (high rate): $1,160.00

    AETNA BETTER rate: $883

    Gross Charge: $2,200.00

    Cash Price: $2,200.00

    Billing Code: #124

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    AETNA BETTER rate: $0

    Gross Charge: $2,200.00

    Cash Price: $2,200.00

    Billing Code: #124

    De-Identified (low rate): $650

    De-Identified (high rate): $1,160.00

    AETNA BETTER rate: $883

    Gross Charge: $2,200.00

    Cash Price: $2,200.00

    Billing Code: #124

    De-Identified (low rate): $110

    De-Identified (high rate): $110

    AETNA BETTER rate: $0

    Gross Charge: $2,200.00

    Cash Price: $2,200.00

    Billing Code: #124

    De-Identified (low rate): $650

    De-Identified (high rate): $1,160

    AETNA BETTER rate: $883

    Gross Charge: $2,200.00

    Cash Price: $2,200.00

    Billing Code: #128

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    AETNA BETTER rate: $0

    Gross Charge: $2,200.00

    Cash Price: $2,200.00

    Billing Code: #128

    De-Identified (low rate): $538

    De-Identified (high rate): $1,160.10

    AETNA BETTER rate: $883

    Gross Charge: $0

    Cash Price: $0

    Billing Code: #0

    De-Identified (low rate): $830

    De-Identified (high rate): $960

    ALL SAVERS rate: $0

    Gross Charge: $0

    Cash Price: $0

    Billing Code: #0

    De-Identified (low rate): $960

    De-Identified (high rate): $960

    ALL SAVERS rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #126

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    ALL SAVERS rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #126

    De-Identified (low rate): $690

    De-Identified (high rate): $1,160.10

    ALL SAVERS rate: $730

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $100

    De-Identified (high rate): $100

    ALL SAVERS rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $650

    De-Identified (high rate): $1,160.10

    ALL SAVERS rate: $707

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $110

    De-Identified (high rate): $110

    ALL SAVERS rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $650

    De-Identified (high rate): $1,160.10

    ALL SAVERS rate: $707

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #128

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    ALL SAVERS rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #128

    De-Identified (low rate): $538

    De-Identified (high rate): $1,160.10

    ALL SAVERS rate: $0

    Gross Charge: $0

    Cash Price: $0

    Billing Code: #0

    De-Identified (low rate): $830

    De-Identified (high rate): $960

    AMBETTER COMMERCIAL rate: $0

    Gross Charge: $0

    Cash Price: $0

    Billing Code: #0

    De-Identified (low rate): $960

    De-Identified (high rate): $960

    AMBETTER COMMERCIAL rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #126

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    AMBETTER COMMERCIAL rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #126

    De-Identified (low rate): $690

    De-Identified (high rate): $1,160.10

    AMBETTER COMMERCIAL rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    AMBETTER COMMERCIAL rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $650

    De-Identified (high rate): $1,160.10

    AMBETTER COMMERCIAL rate: $650

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $110

    De-Identified (high rate): $110

    AMBETTER COMMERCIAL rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $650

    De-Identified (high rate): $1,160.10

    AMBETTER COMMERCIAL rate: $650

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #128

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    AMBETTER COMMERCIAL rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #128

    De-Identified (low rate): $538

    De-Identified (high rate): $1,160.10

    AMBETTER COMMERCIAL rate: $0

    Gross Charge: $0

    Cash Price: $0

    Billing Code: #0

    De-Identified (low rate): $830

    De-Identified (high rate): $960

    BCBS MEDICARE rate: $960

    Gross Charge: $0

    Cash Price: $0

    Billing Code: #0

    De-Identified (low rate): $960

    De-Identified (high rate): $960

    BCBS MEDICARE rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #126

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    BCBS MEDICARE rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #126

    De-Identified (low rate): $690

    De-Identified (high rate): $1,160.10

    BCBS MEDICARE rate: $908.10

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    BCBS MEDICARE rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $650

    De-Identified (high rate): $1,160.10

    BCBS MEDICARE rate: $908.10

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $110

    De-Identified (high rate): $110

    BCBS MEDICARE rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $650

    De-Identified (high rate): $1,160.10

    BCBS MEDICARE rate: $908.10

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #128

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    BCBS MEDICARE rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #128

    De-Identified (low rate): $538

    De-Identified (high rate): $1,160.10

    BCBS MEDICARE rate: $605.40

    Gross Charge: $0

    Cash Price: $0

    Billing Code: #0

    De-Identified (low rate): $830

    De-Identified (high rate): $960

    BEACON HEALTH STRATE rate: $0

    Gross Charge: $0

    Cash Price: $0

    Billing Code: #0

    De-Identified (low rate): $960

    De-Identified (high rate): $960

    BEACON HEALTH STRATE rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #126

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    BEACON HEALTH STRATE rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #126

    De-Identified (low rate): $690

    De-Identified (high rate): $1,160.10

    BEACON HEALTH STRATE rate: $690

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    BEACON HEALTH STRATE rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $650

    De-Identified (high rate): $1,160.10

    BEACON HEALTH STRATE rate: $769

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $110

    De-Identified (high rate): $110

    BEACON HEALTH STRATE rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $650

    De-Identified (high rate): $1,160.10

    BEACON HEALTH STRATE rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #128

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    BEACON HEALTH STRATE rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #128

    De-Identified (low rate): $538

    De-Identified (high rate): $1,160.10

    BEACON HEALTH STRATE rate: $769

    Gross Charge: $0

    Cash Price: $0

    Billing Code: #0

    De-Identified (low rate): $830

    De-Identified (high rate): $960

    BEACON HLTH OPTIONS rate: $0

    Gross Charge: $0

    Cash Price: $0

    Billing Code: #0

    De-Identified (low rate): $960

    De-Identified (high rate): $960

    BEACON HLTH OPTIONS rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #126

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    BEACON HLTH OPTIONS rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #126

    De-Identified (low rate): $690

    De-Identified (high rate): $1,160.10

    BEACON HLTH OPTIONS rate: $690

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    BEACON HLTH OPTIONS rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $650

    De-Identified (high rate): $1,160.10

    BEACON HLTH OPTIONS rate: $769

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $110

    De-Identified (high rate): $110

    BEACON HLTH OPTIONS rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $650

    De-Identified (high rate): $1,160.10

    BEACON HLTH OPTIONS rate: $769

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #128

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    BEACON HLTH OPTIONS rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #128

    De-Identified (low rate): $538

    De-Identified (high rate): $1,160.10

    BEACON HLTH OPTIONS rate: $769

    Gross Charge: $0

    Cash Price: $0

    Billing Code: #0

    De-Identified (low rate): $830

    De-Identified (high rate): $960

    BLUE CROSS rate: $0

    Gross Charge: $0

    Cash Price: $0

    Billing Code: #0

    De-Identified (low rate): $960

    De-Identified (high rate): $960

    BLUE CROSS rate: $960

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #126

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    BLUE CROSS rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #126

    De-Identified (low rate): $690

    De-Identified (high rate): $1,160.10

    BLUE CROSS rate: $908.10

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    BLUE CROSS rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $650

    De-Identified (high rate): $1,160.10

    BLUE CROSS rate: $908.10

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $110

    De-Identified (high rate): $110

    BLUE CROSS rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $650

    De-Identified (high rate): $1,160.10

    BLUE CROSS rate: $908.10

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #128

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    BLUE CROSS rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #128

    De-Identified (low rate): $538

    De-Identified (high rate): $1,160.10

    BLUE CROSS rate: $605.40

    Gross Charge: $0

    Cash Price: $0

    Billing Code: #0

    De-Identified (low rate): $830

    De-Identified (high rate): $960

    BLUE CROSS NEW DIREC rate: $0

    Gross Charge: $0

    Cash Price: $0

    Billing Code: #0

    De-Identified (low rate): $960

    De-Identified (high rate): $960

    BLUE CROSS NEW DIREC rate: $960

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #126

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    BLUE CROSS NEW DIREC rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #126

    De-Identified (low rate): $690

    De-Identified (high rate): $1,160.10

    BLUE CROSS NEW DIREC rate: $908.10

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    BLUE CROSS NEW DIREC rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $650

    De-Identified (high rate): $1,160.10

    BLUE CROSS NEW DIREC rate: $908.10

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $110

    De-Identified (high rate): $110

    BLUE CROSS NEW DIREC rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $650

    De-Identified (high rate): $1,160.10

    BLUE CROSS NEW DIREC rate: $908.10

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #128

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    BLUE CROSS NEW DIREC rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #128

    De-Identified (low rate): $538

    De-Identified (high rate): $1,160.10

    BLUE CROSS NEW DIREC rate: $605.40

    Gross Charge: $0

    Cash Price: $0

    Billing Code: #0

    De-Identified (low rate): $830

    De-Identified (high rate): $960

    BRIGHT HEALTH rate: $0

    Gross Charge: $0

    Cash Price: $0

    Billing Code: #0

    De-Identified (low rate): $960

    De-Identified (high rate): $960

    BRIGHT HEALTH rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #126

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    BRIGHT HEALTH rate: $110

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #126

    De-Identified (low rate): $690

    De-Identified (high rate): $1,160.10

    BRIGHT HEALTH rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    BRIGHT HEALTH rate: $110

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $650

    De-Identified (high rate): $1,160.10

    BRIGHT HEALTH rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $110

    De-Identified (high rate): $110

    BRIGHT HEALTH rate: $110

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $650

    De-Identified (high rate): $1,160.10

    BRIGHT HEALTH rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #128

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    BRIGHT HEALTH rate: $110

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #128

    De-Identified (low rate): $538

    De-Identified (high rate): $1,160.10

    BRIGHT HEALTH rate: $0

    Gross Charge: $0

    Cash Price: $0

    Billing Code: #0

    De-Identified (low rate): $830

    De-Identified (high rate): $960

    CAREPLUS-MAGELLANH rate: $0

    Gross Charge: $0

    Cash Price: $0

    Billing Code: #0

    De-Identified (low rate): $960

    De-Identified (high rate): $960

    CAREPLUS-MAGELLANH rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #126

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    CAREPLUS-MAGELLANH rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #126

    De-Identified (low rate): $690

    De-Identified (high rate): $1,160.10

    CAREPLUS-MAGELLANH rate: $1,699

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    CAREPLUS-MAGELLANH rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $650

    De-Identified (high rate): $1,160.10

    CAREPLUS-MAGELLANH rate: $1,699

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $110

    De-Identified (high rate): $110

    CAREPLUS-MAGELLANH rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $650

    De-Identified (high rate): $1,160.10

    CAREPLUS-MAGELLANH rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #128

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    CAREPLUS-MAGELLANH rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #128

    De-Identified (low rate): $538

    De-Identified (high rate): $1,160.10

    CAREPLUS-MAGELLANH rate: $1,699

    Gross Charge: $0

    Cash Price: $0

    Billing Code: #0

    De-Identified (low rate): $830

    De-Identified (high rate): $960

    CENPATICO rate: $0

    Gross Charge: $0

    Cash Price: $0

    Billing Code: #0

    De-Identified (low rate): $960

    De-Identified (high rate): $960

    CENPATICO rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #126

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    CENPATICO rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #126

    De-Identified (low rate): $690

    De-Identified (high rate): $1,160.10

    CENPATICO rate: $750

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    CENPATICO rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $650

    De-Identified (high rate): $1,160.10

    CENPATICO rate: $1,468

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $110

    De-Identified (high rate): $110

    CENPATICO rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $650

    De-Identified (high rate): $1,160.10

    CENPATICO rate: $1,468

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #128

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    CENPATICO rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #128

    De-Identified (low rate): $538

    De-Identified (high rate): $1,160.10

    CENPATICO rate: $718

    Gross Charge: $0

    Cash Price: $0

    Billing Code: #0

    De-Identified (low rate): $830

    De-Identified (high rate): $960

    CIGNA rate: $0

    Gross Charge: $0

    Cash Price: $0

    Billing Code: #0

    De-Identified (low rate): $960

    De-Identified (high rate): $960

    CIGNA rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #126

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    CIGNA rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #126

    De-Identified (low rate): $690

    De-Identified (high rate): $1,160.10

    CIGNA rate: $890

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    CIGNA rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $650

    De-Identified (high rate): $1,160.10

    CIGNA rate: $890

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $110

    De-Identified (high rate): $110

    CIGNA rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $650

    De-Identified (high rate): $1,160.10

    CIGNA rate: $890

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #128

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    CIGNA rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #128

    De-Identified (low rate): $538

    De-Identified (high rate): $1,160.10

    CIGNA rate: $890

    Gross Charge: $0

    Cash Price: $0

    Billing Code: #0

    De-Identified (low rate): $830

    De-Identified (high rate): $960

    CIGNA HEALTHSPRING rate: $0

    Gross Charge: $0

    Cash Price: $0

    Billing Code: #0

    De-Identified (low rate): $960

    De-Identified (high rate): $960

    CIGNA HEALTHSPRING rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #126

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    CIGNA HEALTHSPRING rate: $100

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #126

    De-Identified (low rate): $690

    De-Identified (high rate): $1,160.10

    CIGNA HEALTHSPRING rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    CIGNA HEALTHSPRING rate: $100

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $650

    De-Identified (high rate): $1,160.10

    CIGNA HEALTHSPRING rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $110

    De-Identified (high rate): $110

    CIGNA HEALTHSPRING rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $650

    De-Identified (high rate): $1,160.10

    CIGNA HEALTHSPRING rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #128

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    CIGNA HEALTHSPRING rate: $100

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #128

    De-Identified (low rate): $538

    De-Identified (high rate): $1,160.10

    CIGNA HEALTHSPRING rate: $890

    Gross Charge: $0

    Cash Price: $0

    Billing Code: #0

    De-Identified (low rate): $830

    De-Identified (high rate): $960

    COMPSYCH rate: $0

    Gross Charge: $0

    Cash Price: $0

    Billing Code: #0

    De-Identified (low rate): $960

    De-Identified (high rate): $960

    COMPSYCH rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #126

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    COMPSYCH rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #126

    De-Identified (low rate): $690

    De-Identified (high rate): $1,160.10

    COMPSYCH rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    COMPSYCH rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $650

    De-Identified (high rate): $1,160.10

    COMPSYCH rate: $775

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $110

    De-Identified (high rate): $110

    COMPSYCH rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $650

    De-Identified (high rate): $1,160.10

    COMPSYCH rate: $775

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #128

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    COMPSYCH rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #128

    De-Identified (low rate): $538

    De-Identified (high rate): $1,160.10

    COMPSYCH rate: $0

    Gross Charge: $0

    Cash Price: $0

    Billing Code: #0

    De-Identified (low rate): $830

    De-Identified (high rate): $960

    GEHA rate: $0

    Gross Charge: $0

    Cash Price: $0

    Billing Code: #0

    De-Identified (low rate): $960

    De-Identified (high rate): $960

    GEHA rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #126

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    GEHA rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #126

    De-Identified (low rate): $690

    De-Identified (high rate): $1,160.10

    GEHA rate: $727

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    GEHA rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $650

    De-Identified (high rate): $1,160.10

    GEHA rate: $796

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $110

    De-Identified (high rate): $110

    GEHA rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $650

    De-Identified (high rate): $1,160.10

    GEHA rate: $796

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #128

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    GEHA rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #128

    De-Identified (low rate): $538

    De-Identified (high rate): $1,160.10

    GEHA rate: $700

    Gross Charge: $0

    Cash Price: $0

    Billing Code: #0

    De-Identified (low rate): $830

    De-Identified (high rate): $960

    GHI rate: $0

    Gross Charge: $0

    Cash Price: $0

    Billing Code: #0

    De-Identified (low rate): $960

    De-Identified (high rate): $960

    GHI rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #126

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    GHI rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #126

    De-Identified (low rate): $690

    De-Identified (high rate): $1,160.10

    GHI rate: $700

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    GHI rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $650

    De-Identified (high rate): $1,160.10

    GHI rate: $700

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $110

    De-Identified (high rate): $110

    GHI rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $650

    De-Identified (high rate): $1,160.10

    GHI rate: $700

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #128

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    GHI rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #128

    De-Identified (low rate): $538

    De-Identified (high rate): $1,160.10

    GHI rate: $538

    Gross Charge: $0

    Cash Price: $0

    Billing Code: #0

    De-Identified (low rate): $830

    De-Identified (high rate): $960

    HUMANA COMMERCIAL rate: $0

    Gross Charge: $0

    Cash Price: $0

    Billing Code: #0

    De-Identified (low rate): $960

    De-Identified (high rate): $960

    HUMANA COMMERCIAL rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #126

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    HUMANA COMMERCIAL rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #126

    De-Identified (low rate): $690

    De-Identified (high rate): $1,160.10

    HUMANA COMMERCIAL rate: $900

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    HUMANA COMMERCIAL rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $650

    De-Identified (high rate): $1,160.10

    HUMANA COMMERCIAL rate: $900

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $110

    De-Identified (high rate): $110

    HUMANA COMMERCIAL rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $650

    De-Identified (high rate): $1,160.10

    HUMANA COMMERCIAL rate: $900

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #128

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    HUMANA COMMERCIAL rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #128

    De-Identified (low rate): $538

    De-Identified (high rate): $1,160.10

    HUMANA COMMERCIAL rate: $900

    Gross Charge: $0

    Cash Price: $0

    Billing Code: #0

    De-Identified (low rate): $830

    De-Identified (high rate): $960

    HUMANA MEDICARE rate: $0

    Gross Charge: $0

    Cash Price: $0

    Billing Code: #0

    De-Identified (low rate): $960

    De-Identified (high rate): $960

    HUMANA MEDICARE rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #126

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    HUMANA MEDICARE rate: $100

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #126

    De-Identified (low rate): $690

    De-Identified (high rate): $1,160.10

    HUMANA MEDICARE rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    HUMANA MEDICARE rate: $100

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $650

    De-Identified (high rate): $1,160.10

    HUMANA MEDICARE rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $110

    De-Identified (high rate): $110

    HUMANA MEDICARE rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $650

    De-Identified (high rate): $1,160.10

    HUMANA MEDICARE rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #128

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    HUMANA MEDICARE rate: $100

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #128

    De-Identified (low rate): $538

    De-Identified (high rate): $1,160.10

    HUMANA MEDICARE rate: $0

    Gross Charge: $0

    Cash Price: $0

    Billing Code: #0

    De-Identified (low rate): $830

    De-Identified (high rate): $960

    MAGELLAN PINNACLE rate: $0

    Gross Charge: $0

    Cash Price: $0

    Billing Code: #0

    De-Identified (low rate): $960

    De-Identified (high rate): $960

    MAGELLAN PINNACLE rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #126

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    MAGELLAN PINNACLE rate: $100

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #126

    De-Identified (low rate): $690

    De-Identified (high rate): $1,160.10

    MAGELLAN PINNACLE rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    MAGELLAN PINNACLE rate: $100

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $650

    De-Identified (high rate): $1,160.10

    MAGELLAN PINNACLE rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $110

    De-Identified (high rate): $110

    MAGELLAN PINNACLE rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $650

    De-Identified (high rate): $1,160.10

    MAGELLAN PINNACLE rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #128

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    MAGELLAN PINNACLE rate: $100

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #128

    De-Identified (low rate): $538

    De-Identified (high rate): $1,160.10

    MAGELLAN PINNACLE rate: $0

    Gross Charge: $0

    Cash Price: $0

    Billing Code: #0

    De-Identified (low rate): $830

    De-Identified (high rate): $960

    MAGELLAN PINNACLE rate: $0

    Gross Charge: $0

    Cash Price: $0

    Billing Code: #0

    De-Identified (low rate): $960

    De-Identified (high rate): $960

    MAGELLAN PINNACLE rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #126

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    MAGELLAN PINNACLE rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #126

    De-Identified (low rate): $690

    De-Identified (high rate): $1,160.10

    MAGELLAN PINNACLE rate: $1,699

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    MAGELLAN PINNACLE rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $650

    De-Identified (high rate): $1,160.10

    MAGELLAN PINNACLE rate: $1,699

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $110

    De-Identified (high rate): $110

    MAGELLAN PINNACLE rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $650

    De-Identified (high rate): $1,160.10

    MAGELLAN PINNACLE rate: $1,699

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #128

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    MAGELLAN PINNACLE rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #128

    De-Identified (low rate): $538

    De-Identified (high rate): $1,160.10

    MAGELLAN PINNACLE rate: $1,699

    Gross Charge: $0

    Cash Price: $0

    Billing Code: #0

    De-Identified (low rate): $830

    De-Identified (high rate): $960

    MAGELLAN SUMMIT rate: $0

    Gross Charge: $0

    Cash Price: $0

    Billing Code: #0

    De-Identified (low rate): $960

    De-Identified (high rate): $960

    MAGELLAN SUMMIT rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #126

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    MAGELLAN SUMMIT rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #126

    De-Identified (low rate): $690

    De-Identified (high rate): $1,160.10

    MAGELLAN SUMMIT rate: $1,699

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    MAGELLAN SUMMIT rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $650

    De-Identified (high rate): $1,160.10

    MAGELLAN SUMMIT rate: $1,699

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $110

    De-Identified (high rate): $110

    MAGELLAN SUMMIT rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $650

    De-Identified (high rate): $1,160.10

    MAGELLAN SUMMIT rate: $1,699

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #128

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    MAGELLAN SUMMIT rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #128

    De-Identified (low rate): $538

    De-Identified (high rate): $1,160.10

    MAGELLAN SUMMIT rate: $1,699

    Gross Charge: $0

    Cash Price: $0

    Billing Code: #0

    De-Identified (low rate): $830

    De-Identified (high rate): $960

    MOLINA HEALTHCARE rate: $0

    Gross Charge: $0

    Cash Price: $0

    Billing Code: #0

    De-Identified (low rate): $960

    De-Identified (high rate): $960

    MOLINA HEALTHCARE rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #126

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    MOLINA HEALTHCARE rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #126

    De-Identified (low rate): $690

    De-Identified (high rate): $1,160.10

    MOLINA HEALTHCARE rate: $750

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    MOLINA HEALTHCARE rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $650

    De-Identified (high rate): $1,160.10

    MOLINA HEALTHCARE rate: $750

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $110

    De-Identified (high rate): $110

    MOLINA HEALTHCARE rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $650

    De-Identified (high rate): $1,160.10

    MOLINA HEALTHCARE rate: $750

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #128

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    MOLINA HEALTHCARE rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #128

    De-Identified (low rate): $538

    De-Identified (high rate): $1,160.10

    MOLINA HEALTHCARE rate: $750

    Gross Charge: $0

    Cash Price: $0

    Billing Code: #0

    De-Identified (low rate): $830

    De-Identified (high rate): $960

    STUDENT RESOURCES rate: $0

    Gross Charge: $0

    Cash Price: $0

    Billing Code: #0

    De-Identified (low rate): $960

    De-Identified (high rate): $960

    STUDENT RESOURCES rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #126

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    STUDENT RESOURCES rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #126

    De-Identified (low rate): $690

    De-Identified (high rate): $1,160.10

    STUDENT RESOURCES rate: $730

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    STUDENT RESOURCES rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $650

    De-Identified (high rate): $1,160.10

    STUDENT RESOURCES rate: $707

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $110

    De-Identified (high rate): $110

    STUDENT RESOURCES rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $650

    De-Identified (high rate): $1,160.10

    STUDENT RESOURCES rate: $707

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #128

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    STUDENT RESOURCES rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #128

    De-Identified (low rate): $538

    De-Identified (high rate): $1,160.10

    STUDENT RESOURCES rate: $707

    Gross Charge: $0

    Cash Price: $0

    Billing Code: #0

    De-Identified (low rate): $830

    De-Identified (high rate): $960

    TRICARE EAST rate: $0

    Gross Charge: $0

    Cash Price: $0

    Billing Code: #0

    De-Identified (low rate): $960

    De-Identified (high rate): $960

    TRICARE EAST rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #126

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    TRICARE EAST rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #126

    De-Identified (low rate): $690

    De-Identified (high rate): $1,160.10

    TRICARE EAST rate: $1,160.10

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    TRICARE EAST rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $650

    De-Identified (high rate): $1,160.10

    TRICARE EAST rate: $1,160.10

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $110

    De-Identified (high rate): $110

    TRICARE EAST rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $650

    De-Identified (high rate): $1,160.10

    TRICARE EAST rate: $1,160.10

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #128

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    TRICARE EAST rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #128

    De-Identified (low rate): $538

    De-Identified (high rate): $1,160.10

    TRICARE EAST rate: $1,160.10

    Gross Charge: $0

    Cash Price: $0

    Billing Code: #0

    De-Identified (low rate): $830

    De-Identified (high rate): $960

    UBH/OPTUM MCAID rate: $0

    Gross Charge: $0

    Cash Price: $0

    Billing Code: #0

    De-Identified (low rate): $960

    De-Identified (high rate): $960

    UBH/OPTUM MCAID rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #126

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    UBH/OPTUM MCAID rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #126

    De-Identified (low rate): $690

    De-Identified (high rate): $1,160.10

    UBH/OPTUM MCAID rate: $700

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    UBH/OPTUM MCAID rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $650

    De-Identified (high rate): $1,160.10

    UBH/OPTUM MCAID rate: $660

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $110

    De-Identified (high rate): $110

    UBH/OPTUM MCAID rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $650

    De-Identified (high rate): $1,160.10

    UBH/OPTUM MCAID rate: $660

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #128

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    UBH/OPTUM MCAID rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #128

    De-Identified (low rate): $538

    De-Identified (high rate): $1,160.10

    UBH/OPTUM MCAID rate: $660

    Gross Charge: $0

    Cash Price: $0

    Billing Code: #0

    De-Identified (low rate): $830

    De-Identified (high rate): $960

    UBH/OPTUM MEDICARE rate: $830

    Gross Charge: $0

    Cash Price: $0

    Billing Code: #0

    De-Identified (low rate): $960

    De-Identified (high rate): $960

    UBH/OPTUM MEDICARE rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #126

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    UBH/OPTUM MEDICARE rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #126

    De-Identified (low rate): $690

    De-Identified (high rate): $1,160.10

    UBH/OPTUM MEDICARE rate: $785

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    UBH/OPTUM MEDICARE rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $650

    De-Identified (high rate): $1,160.10

    UBH/OPTUM MEDICARE rate: $785

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $110

    De-Identified (high rate): $110

    UBH/OPTUM MEDICARE rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $650

    De-Identified (high rate): $1,160.10

    UBH/OPTUM MEDICARE rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #128

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    UBH/OPTUM MEDICARE rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #128

    De-Identified (low rate): $538

    De-Identified (high rate): $1,160.10

    UBH/OPTUM MEDICARE rate: $785

    Gross Charge: $0

    Cash Price: $0

    Billing Code: #0

    De-Identified (low rate): $830

    De-Identified (high rate): $960

    UMR rate: $0

    Gross Charge: $0

    Cash Price: $0

    Billing Code: #0

    De-Identified (low rate): $960

    De-Identified (high rate): $960

    UMR rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #126

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    UMR rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #126

    De-Identified (low rate): $690

    De-Identified (high rate): $1,160.10

    UMR rate: $730

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    UMR rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $650

    De-Identified (high rate): $1,160.10

    UMR rate: $707

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $110

    De-Identified (high rate): $110

    UMR rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $650

    De-Identified (high rate): $1,160.10

    UMR rate: $707

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #128

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    UMR rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #128

    De-Identified (low rate): $538

    De-Identified (high rate): $1,160.10

    UMR rate: $707

    Gross Charge: $0

    Cash Price: $0

    Billing Code: #0

    De-Identified (low rate): $830

    De-Identified (high rate): $960

    UMR ORLANDO HEALTH rate: $0

    Gross Charge: $0

    Cash Price: $0

    Billing Code: #0

    De-Identified (low rate): $960

    De-Identified (high rate): $960

    UMR ORLANDO HEALTH rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #126

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    UMR ORLANDO HEALTH rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #126

    De-Identified (low rate): $690

    De-Identified (high rate): $1,160.10

    UMR ORLANDO HEALTH rate: $775

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    UMR ORLANDO HEALTH rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $650

    De-Identified (high rate): $1,160.10

    UMR ORLANDO HEALTH rate: $775

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $110

    De-Identified (high rate): $110

    UMR ORLANDO HEALTH rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $650

    De-Identified (high rate): $1,160.10

    UMR ORLANDO HEALTH rate: $775

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #128

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    UMR ORLANDO HEALTH rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #128

    De-Identified (low rate): $538

    De-Identified (high rate): $1,160.10

    UMR ORLANDO HEALTH rate: $775

    Gross Charge: $0

    Cash Price: $0

    Billing Code: #0

    De-Identified (low rate): $830

    De-Identified (high rate): $960

    UNITED BEHAVIORAL rate: $0

    Gross Charge: $0

    Cash Price: $0

    Billing Code: #0

    De-Identified (low rate): $960

    De-Identified (high rate): $960

    UNITED BEHAVIORAL rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #126

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    UNITED BEHAVIORAL rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #126

    De-Identified (low rate): $690

    De-Identified (high rate): $1,160.10

    UNITED BEHAVIORAL rate: $730

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    UNITED BEHAVIORAL rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $650

    De-Identified (high rate): $1,160.10

    UNITED BEHAVIORAL rate: $707

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $110

    De-Identified (high rate): $110

    UNITED BEHAVIORAL rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $650

    De-Identified (high rate): $1,160.10

    UNITED BEHAVIORAL rate: $707

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #128

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    UNITED BEHAVIORAL rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #128

    De-Identified (low rate): $538

    De-Identified (high rate): $1,160.10

    UNITED BEHAVIORAL rate: $707

    Gross Charge: $0

    Cash Price: $0

    Billing Code: #0

    De-Identified (low rate): $830

    De-Identified (high rate): $960

    VALUE OPTIONS rate: $0

    Gross Charge: $0

    Cash Price: $0

    Billing Code: #0

    De-Identified (low rate): $960

    De-Identified (high rate): $960

    VALUE OPTIONS rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #126

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    VALUE OPTIONS rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #126

    De-Identified (low rate): $690

    De-Identified (high rate): $1,160.10

    VALUE OPTIONS rate: $750

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    VALUE OPTIONS rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $650

    De-Identified (high rate): $1,160.10

    VALUE OPTIONS rate: $772

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $110

    De-Identified (high rate): $110

    VALUE OPTIONS rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #124

    De-Identified (low rate): $650

    De-Identified (high rate): $1,160.10

    VALUE OPTIONS rate: $772

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #128

    De-Identified (low rate): $100

    De-Identified (high rate): $110

    VALUE OPTIONS rate: $0

    Gross Charge: $2,200

    Cash Price: $2,200

    Billing Code: #128

    De-Identified (low rate): $538

    De-Identified (high rate): $1,160.10

    VALUE OPTIONS rate: $650

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