|
HC DEVICE NOT RETURNED WATCHPAT
|
Facility
|
IP
|
$4,950.00
|
|
| Hospital Charge Code |
27000604
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$3,118.50 |
| Max. Negotiated Rate |
$4,455.00 |
| Rate for Payer: Aetna Commercial |
$4,207.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,217.50
|
| Rate for Payer: Cash Price |
$3,960.00
|
| Rate for Payer: Cofinity Commercial |
$3,465.00
|
| Rate for Payer: Cofinity Commercial |
$4,257.00
|
| Rate for Payer: Cofinity Medicare Advantage |
$3,465.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,960.00
|
| Rate for Payer: Healthscope Commercial |
$4,455.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4,207.50
|
| Rate for Payer: PHP Commercial |
$4,207.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,217.50
|
| Rate for Payer: Priority Health SBD |
$3,118.50
|
|
|
HC DEVICE NOT RETURNED WATCHPAT
|
Facility
|
OP
|
$4,950.00
|
|
| Hospital Charge Code |
27000604
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1,980.00 |
| Max. Negotiated Rate |
$4,455.00 |
| Rate for Payer: Aetna Commercial |
$4,207.50
|
| Rate for Payer: Aetna Medicare |
$2,475.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,217.50
|
| Rate for Payer: BCBS Complete |
$1,980.00
|
| Rate for Payer: Cash Price |
$3,960.00
|
| Rate for Payer: Cofinity Commercial |
$3,465.00
|
| Rate for Payer: Cofinity Commercial |
$4,257.00
|
| Rate for Payer: Cofinity Medicare Advantage |
$3,465.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,960.00
|
| Rate for Payer: Healthscope Commercial |
$4,455.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4,207.50
|
| Rate for Payer: PHP Commercial |
$4,207.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,217.50
|
| Rate for Payer: Priority Health SBD |
$3,118.50
|
|
|
HC DEVICE NOT RETURNED WATCHPAT
|
Professional
|
Both
|
$5,049.00
|
|
|
Service Code
|
HCPCS 00604
|
| Hospital Charge Code |
27000604
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$2,019.60 |
| Max. Negotiated Rate |
$3,281.85 |
| Rate for Payer: Aetna Medicare |
$2,524.50
|
| Rate for Payer: BCBS Complete |
$2,019.60
|
| Rate for Payer: Cash Price |
$4,039.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,281.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,281.85
|
|
|
HC DEXA BONE DENSITY
|
Facility
|
IP
|
$541.62
|
|
|
Service Code
|
CPT 77080
|
| Hospital Charge Code |
32000260
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$341.22 |
| Max. Negotiated Rate |
$487.46 |
| Rate for Payer: Aetna Commercial |
$460.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$352.05
|
| Rate for Payer: Cash Price |
$433.30
|
| Rate for Payer: Cofinity Commercial |
$379.13
|
| Rate for Payer: Cofinity Commercial |
$465.79
|
| Rate for Payer: Cofinity Medicare Advantage |
$379.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$433.30
|
| Rate for Payer: Healthscope Commercial |
$487.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$460.38
|
| Rate for Payer: PHP Commercial |
$460.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$352.05
|
| Rate for Payer: Priority Health SBD |
$341.22
|
|
|
HC DEXA BONE DENSITY
|
Facility
|
OP
|
$541.62
|
|
|
Service Code
|
CPT 77080
|
| Hospital Charge Code |
32000260
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$55.59 |
| Max. Negotiated Rate |
$487.46 |
| Rate for Payer: Aetna Commercial |
$460.38
|
| Rate for Payer: Aetna Medicare |
$107.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$352.05
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$129.64
|
| Rate for Payer: Amish Plain Church Group Commercial |
$129.64
|
| Rate for Payer: BCBS Complete |
$58.37
|
| Rate for Payer: BCBS MAPPO |
$103.71
|
| Rate for Payer: BCN Medicare Advantage |
$103.71
|
| Rate for Payer: Cash Price |
$433.30
|
| Rate for Payer: Cash Price |
$433.30
|
| Rate for Payer: Cofinity Commercial |
$465.79
|
| Rate for Payer: Cofinity Commercial |
$379.13
|
| Rate for Payer: Cofinity Medicare Advantage |
$379.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$433.30
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$103.71
|
| Rate for Payer: Healthscope Commercial |
$487.46
|
| Rate for Payer: Mclaren Medicaid |
$55.59
|
| Rate for Payer: Mclaren Medicare |
$103.71
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$108.90
|
| Rate for Payer: Meridian Medicaid |
$58.37
|
| Rate for Payer: MI Amish Medical Board Commercial |
$119.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$460.38
|
| Rate for Payer: PACE Medicare |
$98.52
|
| Rate for Payer: PACE SWMI |
$103.71
|
| Rate for Payer: PHP Commercial |
$460.38
|
| Rate for Payer: PHP Medicare Advantage |
$103.71
|
| Rate for Payer: Priority Health Choice Medicaid |
$55.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$352.05
|
| Rate for Payer: Priority Health Medicare |
$103.71
|
| Rate for Payer: Priority Health SBD |
$341.22
|
| Rate for Payer: Railroad Medicare Medicare |
$103.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$291.93
|
| Rate for Payer: UHC Core |
$400.80
|
| Rate for Payer: UHC Dual Complete DSNP |
$103.71
|
| Rate for Payer: UHC Exchange |
$400.80
|
| Rate for Payer: UHC Medicare Advantage |
$103.71
|
| Rate for Payer: UHCCP Medicaid |
$58.39
|
| Rate for Payer: VA VA |
$103.71
|
|
|
HC DEXA BONE DENSITY APPENDICULAR
|
Facility
|
OP
|
$204.23
|
|
|
Service Code
|
CPT 77081
|
| Hospital Charge Code |
32000261
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$46.03 |
| Max. Negotiated Rate |
$241.72 |
| Rate for Payer: Aetna Commercial |
$173.60
|
| Rate for Payer: Aetna Medicare |
$89.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$132.75
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$107.34
|
| Rate for Payer: Amish Plain Church Group Commercial |
$107.34
|
| Rate for Payer: BCBS Complete |
$48.33
|
| Rate for Payer: BCBS MAPPO |
$85.87
|
| Rate for Payer: BCN Medicare Advantage |
$85.87
|
| Rate for Payer: Cash Price |
$163.38
|
| Rate for Payer: Cash Price |
$163.38
|
| Rate for Payer: Cofinity Commercial |
$175.64
|
| Rate for Payer: Cofinity Commercial |
$142.96
|
| Rate for Payer: Cofinity Medicare Advantage |
$142.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$163.38
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$85.87
|
| Rate for Payer: Healthscope Commercial |
$183.81
|
| Rate for Payer: Mclaren Medicaid |
$46.03
|
| Rate for Payer: Mclaren Medicare |
$85.87
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$90.16
|
| Rate for Payer: Meridian Medicaid |
$48.33
|
| Rate for Payer: MI Amish Medical Board Commercial |
$98.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$173.60
|
| Rate for Payer: PACE Medicare |
$81.58
|
| Rate for Payer: PACE SWMI |
$85.87
|
| Rate for Payer: PHP Commercial |
$173.60
|
| Rate for Payer: PHP Medicare Advantage |
$85.87
|
| Rate for Payer: Priority Health Choice Medicaid |
$46.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$132.75
|
| Rate for Payer: Priority Health Medicare |
$85.87
|
| Rate for Payer: Priority Health SBD |
$128.66
|
| Rate for Payer: Railroad Medicare Medicare |
$85.87
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$241.72
|
| Rate for Payer: UHC Core |
$151.13
|
| Rate for Payer: UHC Dual Complete DSNP |
$85.87
|
| Rate for Payer: UHC Exchange |
$151.13
|
| Rate for Payer: UHC Medicare Advantage |
$85.87
|
| Rate for Payer: UHCCP Medicaid |
$48.34
|
| Rate for Payer: VA VA |
$85.87
|
|
|
HC DEXA BONE DENSITY APPENDICULAR
|
Facility
|
IP
|
$204.23
|
|
|
Service Code
|
CPT 77081
|
| Hospital Charge Code |
32000261
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$128.66 |
| Max. Negotiated Rate |
$183.81 |
| Rate for Payer: Aetna Commercial |
$173.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$132.75
|
| Rate for Payer: Cash Price |
$163.38
|
| Rate for Payer: Cofinity Commercial |
$142.96
|
| Rate for Payer: Cofinity Commercial |
$175.64
|
| Rate for Payer: Cofinity Medicare Advantage |
$142.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$163.38
|
| Rate for Payer: Healthscope Commercial |
$183.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$173.60
|
| Rate for Payer: PHP Commercial |
$173.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$132.75
|
| Rate for Payer: Priority Health SBD |
$128.66
|
|
|
HC DEXAMETHASONE DEXA
|
Facility
|
IP
|
$150.43
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
30100751
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$94.77 |
| Max. Negotiated Rate |
$135.39 |
| Rate for Payer: Aetna Commercial |
$127.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$97.78
|
| Rate for Payer: Cash Price |
$120.34
|
| Rate for Payer: Cofinity Commercial |
$105.30
|
| Rate for Payer: Cofinity Commercial |
$129.37
|
| Rate for Payer: Cofinity Medicare Advantage |
$105.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$120.34
|
| Rate for Payer: Healthscope Commercial |
$135.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$127.87
|
| Rate for Payer: PHP Commercial |
$127.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$97.78
|
| Rate for Payer: Priority Health SBD |
$94.77
|
|
|
HC DEXAMETHASONE DEXA
|
Facility
|
OP
|
$150.43
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
30100751
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$9.99 |
| Max. Negotiated Rate |
$135.39 |
| Rate for Payer: Aetna Commercial |
$127.87
|
| Rate for Payer: Aetna Medicare |
$19.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$97.78
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$23.30
|
| Rate for Payer: Amish Plain Church Group Commercial |
$23.30
|
| Rate for Payer: BCBS Complete |
$10.49
|
| Rate for Payer: BCBS MAPPO |
$18.64
|
| Rate for Payer: BCN Medicare Advantage |
$18.64
|
| Rate for Payer: Cash Price |
$120.34
|
| Rate for Payer: Cash Price |
$120.34
|
| Rate for Payer: Cofinity Commercial |
$129.37
|
| Rate for Payer: Cofinity Commercial |
$105.30
|
| Rate for Payer: Cofinity Medicare Advantage |
$105.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$120.34
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$18.64
|
| Rate for Payer: Healthscope Commercial |
$135.39
|
| Rate for Payer: Mclaren Medicaid |
$9.99
|
| Rate for Payer: Mclaren Medicare |
$18.64
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$19.57
|
| Rate for Payer: Meridian Medicaid |
$10.49
|
| Rate for Payer: MI Amish Medical Board Commercial |
$21.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$127.87
|
| Rate for Payer: PACE Medicare |
$17.71
|
| Rate for Payer: PACE SWMI |
$18.64
|
| Rate for Payer: PHP Commercial |
$127.87
|
| Rate for Payer: PHP Medicare Advantage |
$18.64
|
| Rate for Payer: Priority Health Choice Medicaid |
$9.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$97.78
|
| Rate for Payer: Priority Health Medicare |
$18.64
|
| Rate for Payer: Priority Health SBD |
$94.77
|
| Rate for Payer: Railroad Medicare Medicare |
$18.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$52.47
|
| Rate for Payer: UHC Dual Complete DSNP |
$18.64
|
| Rate for Payer: UHC Medicare Advantage |
$18.64
|
| Rate for Payer: UHCCP Medicaid |
$10.49
|
| Rate for Payer: VA VA |
$18.64
|
|
|
HC DEXAMETHASONE SODIUM PHOS, PER 1 MG
|
Facility
|
IP
|
$10.40
|
|
|
Service Code
|
HCPCS J1100
|
| Hospital Charge Code |
63600138
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.55 |
| Max. Negotiated Rate |
$9.36 |
| Rate for Payer: Aetna Commercial |
$8.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.76
|
| Rate for Payer: Cash Price |
$8.32
|
| Rate for Payer: Cofinity Commercial |
$7.28
|
| Rate for Payer: Cofinity Commercial |
$8.94
|
| Rate for Payer: Cofinity Medicare Advantage |
$7.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.32
|
| Rate for Payer: Healthscope Commercial |
$9.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.84
|
| Rate for Payer: PHP Commercial |
$8.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.76
|
| Rate for Payer: Priority Health SBD |
$6.55
|
|
|
HC DEXAMETHASONE SODIUM PHOS, PER 1 MG
|
Facility
|
OP
|
$10.40
|
|
|
Service Code
|
HCPCS J1100
|
| Hospital Charge Code |
63600138
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.16 |
| Max. Negotiated Rate |
$9.36 |
| Rate for Payer: Aetna Commercial |
$8.84
|
| Rate for Payer: Aetna Medicare |
$5.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.76
|
| Rate for Payer: BCBS Complete |
$4.16
|
| Rate for Payer: Cash Price |
$8.32
|
| Rate for Payer: Cofinity Commercial |
$7.28
|
| Rate for Payer: Cofinity Commercial |
$8.94
|
| Rate for Payer: Cofinity Medicare Advantage |
$7.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.32
|
| Rate for Payer: Healthscope Commercial |
$9.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.84
|
| Rate for Payer: PHP Commercial |
$8.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.76
|
| Rate for Payer: Priority Health SBD |
$6.55
|
|
|
HC DGTZ GLS MCRSCP MPHMTRC ALYS
|
Facility
|
OP
|
$18.72
|
|
|
Service Code
|
CPT 0763T
|
| Hospital Charge Code |
31200021
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$7.49 |
| Max. Negotiated Rate |
$16.85 |
| Rate for Payer: Aetna Commercial |
$15.91
|
| Rate for Payer: Aetna Medicare |
$9.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.17
|
| Rate for Payer: BCBS Complete |
$7.49
|
| Rate for Payer: Cash Price |
$14.98
|
| Rate for Payer: Cofinity Commercial |
$13.10
|
| Rate for Payer: Cofinity Commercial |
$16.10
|
| Rate for Payer: Cofinity Medicare Advantage |
$13.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.98
|
| Rate for Payer: Healthscope Commercial |
$16.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.91
|
| Rate for Payer: PHP Commercial |
$15.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.17
|
| Rate for Payer: Priority Health SBD |
$11.79
|
|
|
HC DGTZ GLS MCRSCP MPHMTRC ALYS
|
Facility
|
IP
|
$18.72
|
|
|
Service Code
|
CPT 0763T
|
| Hospital Charge Code |
31200021
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$11.79 |
| Max. Negotiated Rate |
$16.85 |
| Rate for Payer: Aetna Commercial |
$15.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.17
|
| Rate for Payer: Cash Price |
$14.98
|
| Rate for Payer: Cofinity Commercial |
$13.10
|
| Rate for Payer: Cofinity Commercial |
$16.10
|
| Rate for Payer: Cofinity Medicare Advantage |
$13.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.98
|
| Rate for Payer: Healthscope Commercial |
$16.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.91
|
| Rate for Payer: PHP Commercial |
$15.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.17
|
| Rate for Payer: Priority Health SBD |
$11.79
|
|
|
HC DGTZ GLS MCRSCP SLD LEVEL II
|
Facility
|
IP
|
$18.72
|
|
|
Service Code
|
CPT 0751T
|
| Hospital Charge Code |
31200009
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$11.79 |
| Max. Negotiated Rate |
$16.85 |
| Rate for Payer: Aetna Commercial |
$15.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.17
|
| Rate for Payer: Cash Price |
$14.98
|
| Rate for Payer: Cofinity Commercial |
$13.10
|
| Rate for Payer: Cofinity Commercial |
$16.10
|
| Rate for Payer: Cofinity Medicare Advantage |
$13.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.98
|
| Rate for Payer: Healthscope Commercial |
$16.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.91
|
| Rate for Payer: PHP Commercial |
$15.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.17
|
| Rate for Payer: Priority Health SBD |
$11.79
|
|
|
HC DGTZ GLS MCRSCP SLD LEVEL II
|
Facility
|
OP
|
$18.72
|
|
|
Service Code
|
CPT 0751T
|
| Hospital Charge Code |
31200009
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$7.49 |
| Max. Negotiated Rate |
$16.85 |
| Rate for Payer: Aetna Commercial |
$15.91
|
| Rate for Payer: Aetna Medicare |
$9.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.17
|
| Rate for Payer: BCBS Complete |
$7.49
|
| Rate for Payer: Cash Price |
$14.98
|
| Rate for Payer: Cofinity Commercial |
$13.10
|
| Rate for Payer: Cofinity Commercial |
$16.10
|
| Rate for Payer: Cofinity Medicare Advantage |
$13.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.98
|
| Rate for Payer: Healthscope Commercial |
$16.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.91
|
| Rate for Payer: PHP Commercial |
$15.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.17
|
| Rate for Payer: Priority Health SBD |
$11.79
|
|
|
HC DGTZ GLS MCRSCP SLD LEVEL IV
|
Facility
|
OP
|
$18.72
|
|
|
Service Code
|
CPT 0753T
|
| Hospital Charge Code |
31200011
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$7.49 |
| Max. Negotiated Rate |
$16.85 |
| Rate for Payer: Aetna Commercial |
$15.91
|
| Rate for Payer: Aetna Medicare |
$9.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.17
|
| Rate for Payer: BCBS Complete |
$7.49
|
| Rate for Payer: Cash Price |
$14.98
|
| Rate for Payer: Cofinity Commercial |
$13.10
|
| Rate for Payer: Cofinity Commercial |
$16.10
|
| Rate for Payer: Cofinity Medicare Advantage |
$13.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.98
|
| Rate for Payer: Healthscope Commercial |
$16.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.91
|
| Rate for Payer: PHP Commercial |
$15.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.17
|
| Rate for Payer: Priority Health SBD |
$11.79
|
|
|
HC DGTZ GLS MCRSCP SLD LEVEL IV
|
Facility
|
IP
|
$18.72
|
|
|
Service Code
|
CPT 0753T
|
| Hospital Charge Code |
31200011
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$11.79 |
| Max. Negotiated Rate |
$16.85 |
| Rate for Payer: Aetna Commercial |
$15.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.17
|
| Rate for Payer: Cash Price |
$14.98
|
| Rate for Payer: Cofinity Commercial |
$13.10
|
| Rate for Payer: Cofinity Commercial |
$16.10
|
| Rate for Payer: Cofinity Medicare Advantage |
$13.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.98
|
| Rate for Payer: Healthscope Commercial |
$16.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.91
|
| Rate for Payer: PHP Commercial |
$15.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.17
|
| Rate for Payer: Priority Health SBD |
$11.79
|
|
|
HC DGTZ GLS MCRSCP SLD LEVEL V
|
Facility
|
IP
|
$37.41
|
|
|
Service Code
|
CPT 0754T
|
| Hospital Charge Code |
31200012
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$23.57 |
| Max. Negotiated Rate |
$33.67 |
| Rate for Payer: Aetna Commercial |
$31.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$24.32
|
| Rate for Payer: Cash Price |
$29.93
|
| Rate for Payer: Cofinity Commercial |
$26.19
|
| Rate for Payer: Cofinity Commercial |
$32.17
|
| Rate for Payer: Cofinity Medicare Advantage |
$26.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$29.93
|
| Rate for Payer: Healthscope Commercial |
$33.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$31.80
|
| Rate for Payer: PHP Commercial |
$31.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.32
|
| Rate for Payer: Priority Health SBD |
$23.57
|
|
|
HC DGTZ GLS MCRSCP SLD LEVEL V
|
Facility
|
OP
|
$37.41
|
|
|
Service Code
|
CPT 0754T
|
| Hospital Charge Code |
31200012
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$14.96 |
| Max. Negotiated Rate |
$33.67 |
| Rate for Payer: Aetna Commercial |
$31.80
|
| Rate for Payer: Aetna Medicare |
$18.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$24.32
|
| Rate for Payer: BCBS Complete |
$14.96
|
| Rate for Payer: Cash Price |
$29.93
|
| Rate for Payer: Cofinity Commercial |
$26.19
|
| Rate for Payer: Cofinity Commercial |
$32.17
|
| Rate for Payer: Cofinity Medicare Advantage |
$26.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$29.93
|
| Rate for Payer: Healthscope Commercial |
$33.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$31.80
|
| Rate for Payer: PHP Commercial |
$31.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.32
|
| Rate for Payer: Priority Health SBD |
$23.57
|
|
|
HC DGTZ GLS MCRSCP SLD LEVEL VI
|
Facility
|
IP
|
$37.41
|
|
|
Service Code
|
CPT 0755T
|
| Hospital Charge Code |
31200013
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$23.57 |
| Max. Negotiated Rate |
$33.67 |
| Rate for Payer: Aetna Commercial |
$31.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$24.32
|
| Rate for Payer: Cash Price |
$29.93
|
| Rate for Payer: Cofinity Commercial |
$26.19
|
| Rate for Payer: Cofinity Commercial |
$32.17
|
| Rate for Payer: Cofinity Medicare Advantage |
$26.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$29.93
|
| Rate for Payer: Healthscope Commercial |
$33.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$31.80
|
| Rate for Payer: PHP Commercial |
$31.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.32
|
| Rate for Payer: Priority Health SBD |
$23.57
|
|
|
HC DGTZ GLS MCRSCP SLD LEVEL VI
|
Facility
|
OP
|
$37.41
|
|
|
Service Code
|
CPT 0755T
|
| Hospital Charge Code |
31200013
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$14.96 |
| Max. Negotiated Rate |
$33.67 |
| Rate for Payer: Aetna Commercial |
$31.80
|
| Rate for Payer: Aetna Medicare |
$18.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$24.32
|
| Rate for Payer: BCBS Complete |
$14.96
|
| Rate for Payer: Cash Price |
$29.93
|
| Rate for Payer: Cofinity Commercial |
$26.19
|
| Rate for Payer: Cofinity Commercial |
$32.17
|
| Rate for Payer: Cofinity Medicare Advantage |
$26.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$29.93
|
| Rate for Payer: Healthscope Commercial |
$33.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$31.80
|
| Rate for Payer: PHP Commercial |
$31.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.32
|
| Rate for Payer: Priority Health SBD |
$23.57
|
|
|
HC DGTZ GLS MCRSCP SLD LVL III
|
Facility
|
IP
|
$18.72
|
|
|
Service Code
|
CPT 0752T
|
| Hospital Charge Code |
31200010
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$11.79 |
| Max. Negotiated Rate |
$16.85 |
| Rate for Payer: Aetna Commercial |
$15.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.17
|
| Rate for Payer: Cash Price |
$14.98
|
| Rate for Payer: Cofinity Commercial |
$13.10
|
| Rate for Payer: Cofinity Commercial |
$16.10
|
| Rate for Payer: Cofinity Medicare Advantage |
$13.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.98
|
| Rate for Payer: Healthscope Commercial |
$16.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.91
|
| Rate for Payer: PHP Commercial |
$15.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.17
|
| Rate for Payer: Priority Health SBD |
$11.79
|
|
|
HC DGTZ GLS MCRSCP SLD LVL III
|
Facility
|
OP
|
$18.72
|
|
|
Service Code
|
CPT 0752T
|
| Hospital Charge Code |
31200010
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$7.49 |
| Max. Negotiated Rate |
$16.85 |
| Rate for Payer: Aetna Commercial |
$15.91
|
| Rate for Payer: Aetna Medicare |
$9.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.17
|
| Rate for Payer: BCBS Complete |
$7.49
|
| Rate for Payer: Cash Price |
$14.98
|
| Rate for Payer: Cofinity Commercial |
$13.10
|
| Rate for Payer: Cofinity Commercial |
$16.10
|
| Rate for Payer: Cofinity Medicare Advantage |
$13.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.98
|
| Rate for Payer: Healthscope Commercial |
$16.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.91
|
| Rate for Payer: PHP Commercial |
$15.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.17
|
| Rate for Payer: Priority Health SBD |
$11.79
|
|
|
HC DGTZ GLS MCRSCP SLD SPC GRPI
|
Facility
|
OP
|
$18.72
|
|
|
Service Code
|
CPT 0756T
|
| Hospital Charge Code |
31200014
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$7.49 |
| Max. Negotiated Rate |
$16.85 |
| Rate for Payer: Aetna Commercial |
$15.91
|
| Rate for Payer: Aetna Medicare |
$9.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.17
|
| Rate for Payer: BCBS Complete |
$7.49
|
| Rate for Payer: Cash Price |
$14.98
|
| Rate for Payer: Cofinity Commercial |
$13.10
|
| Rate for Payer: Cofinity Commercial |
$16.10
|
| Rate for Payer: Cofinity Medicare Advantage |
$13.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.98
|
| Rate for Payer: Healthscope Commercial |
$16.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.91
|
| Rate for Payer: PHP Commercial |
$15.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.17
|
| Rate for Payer: Priority Health SBD |
$11.79
|
|
|
HC DGTZ GLS MCRSCP SLD SPC GRPI
|
Facility
|
IP
|
$18.72
|
|
|
Service Code
|
CPT 0756T
|
| Hospital Charge Code |
31200014
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$11.79 |
| Max. Negotiated Rate |
$16.85 |
| Rate for Payer: Aetna Commercial |
$15.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.17
|
| Rate for Payer: Cash Price |
$14.98
|
| Rate for Payer: Cofinity Commercial |
$13.10
|
| Rate for Payer: Cofinity Commercial |
$16.10
|
| Rate for Payer: Cofinity Medicare Advantage |
$13.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.98
|
| Rate for Payer: Healthscope Commercial |
$16.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.91
|
| Rate for Payer: PHP Commercial |
$15.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.17
|
| Rate for Payer: Priority Health SBD |
$11.79
|
|
