|
HC GLUCOSE STICK (ACCU-CHEK)
|
Facility
|
IP
|
$9.76
|
|
|
Service Code
|
CPT 82962
|
| Hospital Charge Code |
30000010
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.15 |
| Max. Negotiated Rate |
$8.78 |
| Rate for Payer: Aetna Commercial |
$8.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.34
|
| Rate for Payer: Cash Price |
$7.81
|
| Rate for Payer: Cofinity Advantage |
$6.83
|
| Rate for Payer: Cofinity Commercial |
$8.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.81
|
| Rate for Payer: Healthscope Commercial |
$8.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.30
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$7.32
|
| Rate for Payer: PHP Commercial |
$8.30
|
| Rate for Payer: Priority Health SBD |
$6.15
|
|
|
HC GLUC TOLER 3 SPECIMENS
|
Facility
|
OP
|
$95.93
|
|
|
Service Code
|
CPT 82951
|
| Hospital Charge Code |
30100225
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$6.73 |
| Max. Negotiated Rate |
$86.34 |
| Rate for Payer: Aetna Commercial |
$81.54
|
| Rate for Payer: Aetna Medicare |
$13.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$62.35
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$16.09
|
| Rate for Payer: Amish Plain Church Group Commercial |
$16.09
|
| Rate for Payer: BCBS Complete |
$7.07
|
| Rate for Payer: BCBS MAPPO |
$12.87
|
| Rate for Payer: BCBS Trust/PPO |
$13.72
|
| Rate for Payer: BCN Commercial |
$13.72
|
| Rate for Payer: BCN Medicare Advantage |
$12.87
|
| Rate for Payer: Cash Price |
$76.74
|
| Rate for Payer: Cash Price |
$76.74
|
| Rate for Payer: Cofinity Advantage |
$67.15
|
| Rate for Payer: Cofinity Commercial |
$82.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$76.74
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$12.87
|
| Rate for Payer: Healthscope Commercial |
$86.34
|
| Rate for Payer: Mclaren Medicaid |
$6.73
|
| Rate for Payer: Mclaren Medicare |
$12.87
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$13.51
|
| Rate for Payer: Meridian Medicaid |
$13.51
|
| Rate for Payer: MI Amish Medical Board Commercial |
$14.80
|
| Rate for Payer: Molina Medicare/Medicaid |
$14.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$81.54
|
| Rate for Payer: Nomi Health Commercial |
$38.61
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$71.95
|
| Rate for Payer: PACE Medicare |
$12.23
|
| Rate for Payer: PACE SWMI |
$12.87
|
| Rate for Payer: PHP Commercial |
$81.54
|
| Rate for Payer: PHP Medicare Advantage |
$12.87
|
| Rate for Payer: Priority Health Choice Medicaid |
$6.73
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$12.87
|
| Rate for Payer: Priority Health Medicare |
$12.87
|
| Rate for Payer: Priority Health SBD |
$60.44
|
| Rate for Payer: Priority Health Tiered Network |
$10.30
|
| Rate for Payer: Railroad Medicare Medicare |
$12.87
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$19.31
|
| Rate for Payer: UHC Core |
$19.31
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$12.87
|
| Rate for Payer: UHC Exchange |
$19.31
|
| Rate for Payer: UHC Medicaid |
$6.73
|
| Rate for Payer: UHCCP Medicaid |
$6.73
|
| Rate for Payer: VA VA |
$12.87
|
|
|
HC GLUC TOLER 3 SPECIMENS
|
Facility
|
IP
|
$95.93
|
|
|
Service Code
|
CPT 82951
|
| Hospital Charge Code |
30100225
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$60.44 |
| Max. Negotiated Rate |
$86.34 |
| Rate for Payer: Aetna Commercial |
$81.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$62.35
|
| Rate for Payer: Cash Price |
$76.74
|
| Rate for Payer: Cofinity Advantage |
$67.15
|
| Rate for Payer: Cofinity Commercial |
$82.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$76.74
|
| Rate for Payer: Healthscope Commercial |
$86.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$81.54
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$71.95
|
| Rate for Payer: PHP Commercial |
$81.54
|
| Rate for Payer: Priority Health SBD |
$60.44
|
|
|
HC GLUTAMIC ACID DECARBOXYLASE AB
|
Facility
|
OP
|
$74.91
|
|
|
Service Code
|
CPT 86341
|
| Hospital Charge Code |
30100255
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$12.33 |
| Max. Negotiated Rate |
$67.42 |
| Rate for Payer: Aetna Commercial |
$63.67
|
| Rate for Payer: Aetna Medicare |
$24.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$48.69
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$29.46
|
| Rate for Payer: Amish Plain Church Group Commercial |
$29.46
|
| Rate for Payer: BCBS Complete |
$12.94
|
| Rate for Payer: BCBS MAPPO |
$23.57
|
| Rate for Payer: BCBS Trust/PPO |
$25.13
|
| Rate for Payer: BCN Commercial |
$25.13
|
| Rate for Payer: BCN Medicare Advantage |
$23.57
|
| Rate for Payer: Cash Price |
$59.93
|
| Rate for Payer: Cash Price |
$59.93
|
| Rate for Payer: Cofinity Advantage |
$52.44
|
| Rate for Payer: Cofinity Commercial |
$64.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$59.93
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$23.57
|
| Rate for Payer: Healthscope Commercial |
$67.42
|
| Rate for Payer: Mclaren Medicaid |
$12.33
|
| Rate for Payer: Mclaren Medicare |
$23.57
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$24.75
|
| Rate for Payer: Meridian Medicaid |
$24.75
|
| Rate for Payer: MI Amish Medical Board Commercial |
$27.11
|
| Rate for Payer: Molina Medicare/Medicaid |
$25.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$63.67
|
| Rate for Payer: Nomi Health Commercial |
$35.35
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$56.18
|
| Rate for Payer: PACE Medicare |
$22.39
|
| Rate for Payer: PACE SWMI |
$23.57
|
| Rate for Payer: PHP Commercial |
$63.67
|
| Rate for Payer: PHP Medicare Advantage |
$23.57
|
| Rate for Payer: Priority Health Choice Medicaid |
$12.33
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$23.57
|
| Rate for Payer: Priority Health Medicare |
$23.57
|
| Rate for Payer: Priority Health SBD |
$47.19
|
| Rate for Payer: Priority Health Tiered Network |
$18.86
|
| Rate for Payer: Railroad Medicare Medicare |
$23.57
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$35.36
|
| Rate for Payer: UHC Core |
$35.36
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$23.57
|
| Rate for Payer: UHC Exchange |
$35.36
|
| Rate for Payer: UHC Medicaid |
$12.33
|
| Rate for Payer: UHCCP Medicaid |
$12.33
|
| Rate for Payer: VA VA |
$23.57
|
|
|
HC GLUTAMIC ACID DECARBOXYLASE AB
|
Facility
|
IP
|
$74.91
|
|
|
Service Code
|
CPT 86341
|
| Hospital Charge Code |
30100255
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$47.19 |
| Max. Negotiated Rate |
$67.42 |
| Rate for Payer: Aetna Commercial |
$63.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$48.69
|
| Rate for Payer: Cash Price |
$59.93
|
| Rate for Payer: Cofinity Advantage |
$52.44
|
| Rate for Payer: Cofinity Commercial |
$64.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$59.93
|
| Rate for Payer: Healthscope Commercial |
$67.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$63.67
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$56.18
|
| Rate for Payer: PHP Commercial |
$63.67
|
| Rate for Payer: Priority Health SBD |
$47.19
|
|
|
HC GLYCOHEMOGLOBIN (A1C)
|
Facility
|
OP
|
$37.14
|
|
|
Service Code
|
CPT 83036
|
| Hospital Charge Code |
30100238
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$5.08 |
| Max. Negotiated Rate |
$33.43 |
| Rate for Payer: Aetna Commercial |
$31.57
|
| Rate for Payer: Aetna Medicare |
$10.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$24.14
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$12.14
|
| Rate for Payer: Amish Plain Church Group Commercial |
$12.14
|
| Rate for Payer: BCBS Complete |
$5.33
|
| Rate for Payer: BCBS MAPPO |
$9.71
|
| Rate for Payer: BCBS Trust/PPO |
$10.35
|
| Rate for Payer: BCN Commercial |
$10.35
|
| Rate for Payer: BCN Medicare Advantage |
$9.71
|
| Rate for Payer: Cash Price |
$29.71
|
| Rate for Payer: Cash Price |
$29.71
|
| Rate for Payer: Cofinity Advantage |
$26.00
|
| Rate for Payer: Cofinity Commercial |
$31.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$29.71
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$9.71
|
| Rate for Payer: Healthscope Commercial |
$33.43
|
| Rate for Payer: Mclaren Medicaid |
$5.08
|
| Rate for Payer: Mclaren Medicare |
$9.71
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$10.20
|
| Rate for Payer: Meridian Medicaid |
$10.20
|
| Rate for Payer: MI Amish Medical Board Commercial |
$11.17
|
| Rate for Payer: Molina Medicare/Medicaid |
$10.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$31.57
|
| Rate for Payer: Nomi Health Commercial |
$14.56
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$27.86
|
| Rate for Payer: PACE Medicare |
$9.22
|
| Rate for Payer: PACE SWMI |
$9.71
|
| Rate for Payer: PHP Commercial |
$31.57
|
| Rate for Payer: PHP Medicare Advantage |
$9.71
|
| Rate for Payer: Priority Health Choice Medicaid |
$5.08
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$9.71
|
| Rate for Payer: Priority Health Medicare |
$9.71
|
| Rate for Payer: Priority Health SBD |
$23.40
|
| Rate for Payer: Priority Health Tiered Network |
$7.77
|
| Rate for Payer: Railroad Medicare Medicare |
$9.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$14.57
|
| Rate for Payer: UHC Core |
$14.57
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$9.71
|
| Rate for Payer: UHC Exchange |
$14.57
|
| Rate for Payer: UHC Medicaid |
$5.08
|
| Rate for Payer: UHCCP Medicaid |
$5.08
|
| Rate for Payer: VA VA |
$9.71
|
|
|
HC GLYCOHEMOGLOBIN (A1C)
|
Facility
|
IP
|
$37.14
|
|
|
Service Code
|
CPT 83036
|
| Hospital Charge Code |
30100238
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$23.40 |
| Max. Negotiated Rate |
$33.43 |
| Rate for Payer: Aetna Commercial |
$31.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$24.14
|
| Rate for Payer: Cash Price |
$29.71
|
| Rate for Payer: Cofinity Advantage |
$26.00
|
| Rate for Payer: Cofinity Commercial |
$31.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$29.71
|
| Rate for Payer: Healthscope Commercial |
$33.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$31.57
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$27.86
|
| Rate for Payer: PHP Commercial |
$31.57
|
| Rate for Payer: Priority Health SBD |
$23.40
|
|
|
HC GMU OBSERVATION PER HOUR
|
Facility
|
OP
|
$160.00
|
|
|
Service Code
|
HCPCS G0378
|
| Hospital Charge Code |
76200006
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$64.00 |
| Max. Negotiated Rate |
$1,608.00 |
| Rate for Payer: Aetna Commercial |
$136.00
|
| Rate for Payer: Aetna Medicare |
$80.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$104.00
|
| Rate for Payer: BCBS Complete |
$64.00
|
| Rate for Payer: BCBS Trust/PPO |
$112.58
|
| Rate for Payer: BCN Commercial |
$112.58
|
| Rate for Payer: Cash Price |
$128.00
|
| Rate for Payer: Cash Price |
$128.00
|
| Rate for Payer: Cash Price |
$128.00
|
| Rate for Payer: Cash Price |
$128.00
|
| Rate for Payer: Cofinity Advantage |
$112.00
|
| Rate for Payer: Cofinity Commercial |
$137.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$128.00
|
| Rate for Payer: Healthscope Commercial |
$144.00
|
| Rate for Payer: MI Amish Medical Board Commercial |
$128.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$136.00
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$120.00
|
| Rate for Payer: PHP Commercial |
$136.00
|
| Rate for Payer: Priority Health SBD |
$100.80
|
| Rate for Payer: UHC Medicaid |
$1,608.00
|
| Rate for Payer: UHCCP Medicaid |
$810.00
|
|
|
HC GMU OBSERVATION PER HOUR
|
Facility
|
IP
|
$160.00
|
|
|
Service Code
|
HCPCS G0378
|
| Hospital Charge Code |
76200006
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$100.80 |
| Max. Negotiated Rate |
$144.00 |
| Rate for Payer: Aetna Commercial |
$136.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$104.00
|
| Rate for Payer: Cash Price |
$128.00
|
| Rate for Payer: Cofinity Advantage |
$112.00
|
| Rate for Payer: Cofinity Commercial |
$137.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$128.00
|
| Rate for Payer: Healthscope Commercial |
$144.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$136.00
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$120.00
|
| Rate for Payer: PHP Commercial |
$136.00
|
| Rate for Payer: Priority Health SBD |
$100.80
|
|
|
HC GOLDENROD IGE
|
Facility
|
IP
|
$25.90
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
30200086
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$16.32 |
| Max. Negotiated Rate |
$23.31 |
| Rate for Payer: Aetna Commercial |
$22.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.84
|
| Rate for Payer: Cash Price |
$20.72
|
| Rate for Payer: Cofinity Advantage |
$18.13
|
| Rate for Payer: Cofinity Commercial |
$22.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.72
|
| Rate for Payer: Healthscope Commercial |
$23.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.02
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$19.43
|
| Rate for Payer: PHP Commercial |
$22.02
|
| Rate for Payer: Priority Health SBD |
$16.32
|
|
|
HC GOLDENROD IGE
|
Facility
|
OP
|
$25.90
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
30200086
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$2.73 |
| Max. Negotiated Rate |
$23.31 |
| Rate for Payer: Aetna Commercial |
$22.02
|
| Rate for Payer: Aetna Medicare |
$5.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.84
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6.53
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6.53
|
| Rate for Payer: BCBS Complete |
$2.87
|
| Rate for Payer: BCBS MAPPO |
$5.22
|
| Rate for Payer: BCBS Trust/PPO |
$5.57
|
| Rate for Payer: BCN Commercial |
$5.57
|
| Rate for Payer: BCN Medicare Advantage |
$5.22
|
| Rate for Payer: Cash Price |
$20.72
|
| Rate for Payer: Cash Price |
$20.72
|
| Rate for Payer: Cofinity Advantage |
$18.13
|
| Rate for Payer: Cofinity Commercial |
$22.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.72
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5.22
|
| Rate for Payer: Healthscope Commercial |
$23.31
|
| Rate for Payer: Mclaren Medicaid |
$2.73
|
| Rate for Payer: Mclaren Medicare |
$5.22
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5.48
|
| Rate for Payer: Meridian Medicaid |
$5.48
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6.00
|
| Rate for Payer: Molina Medicare/Medicaid |
$5.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.02
|
| Rate for Payer: Nomi Health Commercial |
$7.83
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$19.43
|
| Rate for Payer: PACE Medicare |
$4.96
|
| Rate for Payer: PACE SWMI |
$5.22
|
| Rate for Payer: PHP Commercial |
$22.02
|
| Rate for Payer: PHP Medicare Advantage |
$5.22
|
| Rate for Payer: Priority Health Choice Medicaid |
$2.73
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$5.22
|
| Rate for Payer: Priority Health Medicare |
$5.22
|
| Rate for Payer: Priority Health SBD |
$16.32
|
| Rate for Payer: Priority Health Tiered Network |
$4.18
|
| Rate for Payer: Railroad Medicare Medicare |
$5.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$7.83
|
| Rate for Payer: UHC Core |
$7.83
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$5.22
|
| Rate for Payer: UHC Exchange |
$7.83
|
| Rate for Payer: UHC Medicaid |
$2.73
|
| Rate for Payer: UHCCP Medicaid |
$2.73
|
| Rate for Payer: VA VA |
$5.22
|
|
|
HC GOLD PROBE HEMOSTASIS
|
Facility
|
IP
|
$624.69
|
|
| Hospital Charge Code |
27000080
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$393.55 |
| Max. Negotiated Rate |
$562.22 |
| Rate for Payer: Aetna Commercial |
$530.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$406.05
|
| Rate for Payer: Cash Price |
$499.75
|
| Rate for Payer: Cofinity Advantage |
$437.28
|
| Rate for Payer: Cofinity Commercial |
$537.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$499.75
|
| Rate for Payer: Healthscope Commercial |
$562.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$530.99
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$468.52
|
| Rate for Payer: PHP Commercial |
$530.99
|
| Rate for Payer: Priority Health SBD |
$393.55
|
|
|
HC GOLD PROBE HEMOSTASIS
|
Facility
|
OP
|
$624.69
|
|
| Hospital Charge Code |
27000080
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$245.50 |
| Max. Negotiated Rate |
$562.22 |
| Rate for Payer: Aetna Commercial |
$530.99
|
| Rate for Payer: Aetna Medicare |
$312.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$406.05
|
| Rate for Payer: BCBS Complete |
$249.88
|
| Rate for Payer: Cash Price |
$499.75
|
| Rate for Payer: Cofinity Advantage |
$437.28
|
| Rate for Payer: Cofinity Commercial |
$537.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$499.75
|
| Rate for Payer: Healthscope Commercial |
$562.22
|
| Rate for Payer: MI Amish Medical Board Commercial |
$499.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$530.99
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$468.52
|
| Rate for Payer: PHP Commercial |
$530.99
|
| Rate for Payer: Priority Health SBD |
$393.55
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$406.05
|
| Rate for Payer: UHC Core |
$325.46
|
| Rate for Payer: UHC Exchange |
$245.50
|
|
|
HC GOOSE FEATHERS IGE
|
Facility
|
IP
|
$25.90
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
30200087
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$16.32 |
| Max. Negotiated Rate |
$23.31 |
| Rate for Payer: Aetna Commercial |
$22.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.84
|
| Rate for Payer: Cash Price |
$20.72
|
| Rate for Payer: Cofinity Advantage |
$18.13
|
| Rate for Payer: Cofinity Commercial |
$22.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.72
|
| Rate for Payer: Healthscope Commercial |
$23.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.02
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$19.43
|
| Rate for Payer: PHP Commercial |
$22.02
|
| Rate for Payer: Priority Health SBD |
$16.32
|
|
|
HC GOOSE FEATHERS IGE
|
Facility
|
OP
|
$25.90
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
30200087
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$2.73 |
| Max. Negotiated Rate |
$23.31 |
| Rate for Payer: Aetna Commercial |
$22.02
|
| Rate for Payer: Aetna Medicare |
$5.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.84
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6.53
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6.53
|
| Rate for Payer: BCBS Complete |
$2.87
|
| Rate for Payer: BCBS MAPPO |
$5.22
|
| Rate for Payer: BCBS Trust/PPO |
$5.57
|
| Rate for Payer: BCN Commercial |
$5.57
|
| Rate for Payer: BCN Medicare Advantage |
$5.22
|
| Rate for Payer: Cash Price |
$20.72
|
| Rate for Payer: Cash Price |
$20.72
|
| Rate for Payer: Cofinity Advantage |
$18.13
|
| Rate for Payer: Cofinity Commercial |
$22.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.72
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5.22
|
| Rate for Payer: Healthscope Commercial |
$23.31
|
| Rate for Payer: Mclaren Medicaid |
$2.73
|
| Rate for Payer: Mclaren Medicare |
$5.22
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5.48
|
| Rate for Payer: Meridian Medicaid |
$5.48
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6.00
|
| Rate for Payer: Molina Medicare/Medicaid |
$5.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.02
|
| Rate for Payer: Nomi Health Commercial |
$7.83
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$19.43
|
| Rate for Payer: PACE Medicare |
$4.96
|
| Rate for Payer: PACE SWMI |
$5.22
|
| Rate for Payer: PHP Commercial |
$22.02
|
| Rate for Payer: PHP Medicare Advantage |
$5.22
|
| Rate for Payer: Priority Health Choice Medicaid |
$2.73
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$5.22
|
| Rate for Payer: Priority Health Medicare |
$5.22
|
| Rate for Payer: Priority Health SBD |
$16.32
|
| Rate for Payer: Priority Health Tiered Network |
$4.18
|
| Rate for Payer: Railroad Medicare Medicare |
$5.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$7.83
|
| Rate for Payer: UHC Core |
$7.83
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$5.22
|
| Rate for Payer: UHC Exchange |
$7.83
|
| Rate for Payer: UHC Medicaid |
$2.73
|
| Rate for Payer: UHCCP Medicaid |
$2.73
|
| Rate for Payer: VA VA |
$5.22
|
|
|
HC GRAFIX PRIME 1.5 X 2 PER SQ CM
|
Facility
|
IP
|
$778.23
|
|
|
Service Code
|
HCPCS Q4133
|
| Hospital Charge Code |
63600159
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$490.28 |
| Max. Negotiated Rate |
$700.41 |
| Rate for Payer: Aetna Commercial |
$661.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$505.85
|
| Rate for Payer: Cash Price |
$622.58
|
| Rate for Payer: Cofinity Advantage |
$544.76
|
| Rate for Payer: Cofinity Commercial |
$669.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$622.58
|
| Rate for Payer: Healthscope Commercial |
$700.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$661.50
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$583.67
|
| Rate for Payer: PHP Commercial |
$661.50
|
| Rate for Payer: Priority Health SBD |
$490.28
|
|
|
HC GRAFIX PRIME 1.5 X 2 PER SQ CM
|
Facility
|
OP
|
$778.23
|
|
|
Service Code
|
HCPCS Q4133
|
| Hospital Charge Code |
63600159
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$64.85 |
| Max. Negotiated Rate |
$700.41 |
| Rate for Payer: Aetna Commercial |
$661.50
|
| Rate for Payer: Aetna Medicare |
$128.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$505.85
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$155.00
|
| Rate for Payer: Amish Plain Church Group Commercial |
$155.00
|
| Rate for Payer: BCBS Complete |
$68.10
|
| Rate for Payer: BCBS MAPPO |
$124.00
|
| Rate for Payer: BCBS Trust/PPO |
$204.72
|
| Rate for Payer: BCN Commercial |
$611.41
|
| Rate for Payer: BCN Medicare Advantage |
$124.00
|
| Rate for Payer: Cash Price |
$622.58
|
| Rate for Payer: Cash Price |
$622.58
|
| Rate for Payer: Cash Price |
$622.58
|
| Rate for Payer: Cofinity Advantage |
$544.76
|
| Rate for Payer: Cofinity Commercial |
$669.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$622.58
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$124.00
|
| Rate for Payer: Healthscope Commercial |
$700.41
|
| Rate for Payer: Mclaren Medicaid |
$64.85
|
| Rate for Payer: Mclaren Medicare |
$124.00
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$130.20
|
| Rate for Payer: Meridian Medicaid |
$130.20
|
| Rate for Payer: MI Amish Medical Board Commercial |
$142.60
|
| Rate for Payer: Molina Medicare/Medicaid |
$136.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$661.50
|
| Rate for Payer: Nomi Health Commercial |
$372.00
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$583.67
|
| Rate for Payer: PACE Medicare |
$117.80
|
| Rate for Payer: PACE SWMI |
$124.00
|
| Rate for Payer: PHP Commercial |
$661.50
|
| Rate for Payer: PHP Medicare Advantage |
$124.00
|
| Rate for Payer: Priority Health Choice Medicaid |
$64.85
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$401.00
|
| Rate for Payer: Priority Health Medicare |
$124.00
|
| Rate for Payer: Priority Health SBD |
$490.28
|
| Rate for Payer: Priority Health Tiered Network |
$320.80
|
| Rate for Payer: Railroad Medicare Medicare |
$124.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$209.78
|
| Rate for Payer: UHC Core |
$209.78
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$124.00
|
| Rate for Payer: UHC Exchange |
$209.78
|
| Rate for Payer: UHC Medicaid |
$64.85
|
| Rate for Payer: UHCCP Medicaid |
$64.85
|
| Rate for Payer: VA VA |
$124.00
|
|
|
HC GRAFIX PRIME (16 MM) DISC PER SQ CM
|
Facility
|
OP
|
$787.95
|
|
|
Service Code
|
HCPCS Q4133
|
| Hospital Charge Code |
63600158
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$64.85 |
| Max. Negotiated Rate |
$709.15 |
| Rate for Payer: Aetna Commercial |
$669.76
|
| Rate for Payer: Aetna Medicare |
$128.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$512.17
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$155.00
|
| Rate for Payer: Amish Plain Church Group Commercial |
$155.00
|
| Rate for Payer: BCBS Complete |
$68.10
|
| Rate for Payer: BCBS MAPPO |
$124.00
|
| Rate for Payer: BCBS Trust/PPO |
$204.72
|
| Rate for Payer: BCN Commercial |
$611.41
|
| Rate for Payer: BCN Medicare Advantage |
$124.00
|
| Rate for Payer: Cash Price |
$630.36
|
| Rate for Payer: Cash Price |
$630.36
|
| Rate for Payer: Cash Price |
$630.36
|
| Rate for Payer: Cofinity Advantage |
$551.57
|
| Rate for Payer: Cofinity Commercial |
$677.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$630.36
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$124.00
|
| Rate for Payer: Healthscope Commercial |
$709.15
|
| Rate for Payer: Mclaren Medicaid |
$64.85
|
| Rate for Payer: Mclaren Medicare |
$124.00
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$130.20
|
| Rate for Payer: Meridian Medicaid |
$130.20
|
| Rate for Payer: MI Amish Medical Board Commercial |
$142.60
|
| Rate for Payer: Molina Medicare/Medicaid |
$136.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$669.76
|
| Rate for Payer: Nomi Health Commercial |
$372.00
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$590.96
|
| Rate for Payer: PACE Medicare |
$117.80
|
| Rate for Payer: PACE SWMI |
$124.00
|
| Rate for Payer: PHP Commercial |
$669.76
|
| Rate for Payer: PHP Medicare Advantage |
$124.00
|
| Rate for Payer: Priority Health Choice Medicaid |
$64.85
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$401.00
|
| Rate for Payer: Priority Health Medicare |
$124.00
|
| Rate for Payer: Priority Health SBD |
$496.41
|
| Rate for Payer: Priority Health Tiered Network |
$320.80
|
| Rate for Payer: Railroad Medicare Medicare |
$124.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$209.78
|
| Rate for Payer: UHC Core |
$209.78
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$124.00
|
| Rate for Payer: UHC Exchange |
$209.78
|
| Rate for Payer: UHC Medicaid |
$64.85
|
| Rate for Payer: UHCCP Medicaid |
$64.85
|
| Rate for Payer: VA VA |
$124.00
|
|
|
HC GRAFIX PRIME (16 MM) DISC PER SQ CM
|
Facility
|
IP
|
$787.95
|
|
|
Service Code
|
HCPCS Q4133
|
| Hospital Charge Code |
63600158
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$496.41 |
| Max. Negotiated Rate |
$709.15 |
| Rate for Payer: Aetna Commercial |
$669.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$512.17
|
| Rate for Payer: Cash Price |
$630.36
|
| Rate for Payer: Cofinity Advantage |
$551.57
|
| Rate for Payer: Cofinity Commercial |
$677.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$630.36
|
| Rate for Payer: Healthscope Commercial |
$709.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$669.76
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$590.96
|
| Rate for Payer: PHP Commercial |
$669.76
|
| Rate for Payer: Priority Health SBD |
$496.41
|
|
|
HC GRAFIX PRIME 2 X 3 PER SQ CM
|
Facility
|
OP
|
$486.40
|
|
|
Service Code
|
HCPCS Q4133
|
| Hospital Charge Code |
63600160
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$64.85 |
| Max. Negotiated Rate |
$611.41 |
| Rate for Payer: Aetna Commercial |
$413.44
|
| Rate for Payer: Aetna Medicare |
$128.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$316.16
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$155.00
|
| Rate for Payer: Amish Plain Church Group Commercial |
$155.00
|
| Rate for Payer: BCBS Complete |
$68.10
|
| Rate for Payer: BCBS MAPPO |
$124.00
|
| Rate for Payer: BCBS Trust/PPO |
$204.72
|
| Rate for Payer: BCN Commercial |
$611.41
|
| Rate for Payer: BCN Medicare Advantage |
$124.00
|
| Rate for Payer: Cash Price |
$389.12
|
| Rate for Payer: Cash Price |
$389.12
|
| Rate for Payer: Cash Price |
$389.12
|
| Rate for Payer: Cofinity Advantage |
$340.48
|
| Rate for Payer: Cofinity Commercial |
$418.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$389.12
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$124.00
|
| Rate for Payer: Healthscope Commercial |
$437.76
|
| Rate for Payer: Mclaren Medicaid |
$64.85
|
| Rate for Payer: Mclaren Medicare |
$124.00
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$130.20
|
| Rate for Payer: Meridian Medicaid |
$130.20
|
| Rate for Payer: MI Amish Medical Board Commercial |
$142.60
|
| Rate for Payer: Molina Medicare/Medicaid |
$136.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$413.44
|
| Rate for Payer: Nomi Health Commercial |
$372.00
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$364.80
|
| Rate for Payer: PACE Medicare |
$117.80
|
| Rate for Payer: PACE SWMI |
$124.00
|
| Rate for Payer: PHP Commercial |
$413.44
|
| Rate for Payer: PHP Medicare Advantage |
$124.00
|
| Rate for Payer: Priority Health Choice Medicaid |
$64.85
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$401.00
|
| Rate for Payer: Priority Health Medicare |
$124.00
|
| Rate for Payer: Priority Health SBD |
$306.43
|
| Rate for Payer: Priority Health Tiered Network |
$320.80
|
| Rate for Payer: Railroad Medicare Medicare |
$124.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$209.78
|
| Rate for Payer: UHC Core |
$209.78
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$124.00
|
| Rate for Payer: UHC Exchange |
$209.78
|
| Rate for Payer: UHC Medicaid |
$64.85
|
| Rate for Payer: UHCCP Medicaid |
$64.85
|
| Rate for Payer: VA VA |
$124.00
|
|
|
HC GRAFIX PRIME 2 X 3 PER SQ CM
|
Facility
|
IP
|
$486.40
|
|
|
Service Code
|
HCPCS Q4133
|
| Hospital Charge Code |
63600160
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$306.43 |
| Max. Negotiated Rate |
$437.76 |
| Rate for Payer: Aetna Commercial |
$413.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$316.16
|
| Rate for Payer: Cash Price |
$389.12
|
| Rate for Payer: Cofinity Advantage |
$340.48
|
| Rate for Payer: Cofinity Commercial |
$418.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$389.12
|
| Rate for Payer: Healthscope Commercial |
$437.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$413.44
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$364.80
|
| Rate for Payer: PHP Commercial |
$413.44
|
| Rate for Payer: Priority Health SBD |
$306.43
|
|
|
HC GRAFIX PRIME 3 X 3 PER SQ CM
|
Facility
|
IP
|
$343.19
|
|
|
Service Code
|
HCPCS Q4133
|
| Hospital Charge Code |
63600244
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$216.21 |
| Max. Negotiated Rate |
$308.87 |
| Rate for Payer: Aetna Commercial |
$291.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$223.07
|
| Rate for Payer: Cash Price |
$274.55
|
| Rate for Payer: Cofinity Advantage |
$240.23
|
| Rate for Payer: Cofinity Commercial |
$295.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$274.55
|
| Rate for Payer: Healthscope Commercial |
$308.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$291.71
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$257.39
|
| Rate for Payer: PHP Commercial |
$291.71
|
| Rate for Payer: Priority Health SBD |
$216.21
|
|
|
HC GRAFIX PRIME 3 X 3 PER SQ CM
|
Facility
|
OP
|
$343.19
|
|
|
Service Code
|
HCPCS Q4133
|
| Hospital Charge Code |
63600244
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$64.85 |
| Max. Negotiated Rate |
$611.41 |
| Rate for Payer: Aetna Commercial |
$291.71
|
| Rate for Payer: Aetna Medicare |
$128.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$223.07
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$155.00
|
| Rate for Payer: Amish Plain Church Group Commercial |
$155.00
|
| Rate for Payer: BCBS Complete |
$68.10
|
| Rate for Payer: BCBS MAPPO |
$124.00
|
| Rate for Payer: BCBS Trust/PPO |
$204.72
|
| Rate for Payer: BCN Commercial |
$611.41
|
| Rate for Payer: BCN Medicare Advantage |
$124.00
|
| Rate for Payer: Cash Price |
$274.55
|
| Rate for Payer: Cash Price |
$274.55
|
| Rate for Payer: Cash Price |
$274.55
|
| Rate for Payer: Cofinity Advantage |
$240.23
|
| Rate for Payer: Cofinity Commercial |
$295.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$274.55
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$124.00
|
| Rate for Payer: Healthscope Commercial |
$308.87
|
| Rate for Payer: Mclaren Medicaid |
$64.85
|
| Rate for Payer: Mclaren Medicare |
$124.00
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$130.20
|
| Rate for Payer: Meridian Medicaid |
$130.20
|
| Rate for Payer: MI Amish Medical Board Commercial |
$142.60
|
| Rate for Payer: Molina Medicare/Medicaid |
$136.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$291.71
|
| Rate for Payer: Nomi Health Commercial |
$372.00
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$257.39
|
| Rate for Payer: PACE Medicare |
$117.80
|
| Rate for Payer: PACE SWMI |
$124.00
|
| Rate for Payer: PHP Commercial |
$291.71
|
| Rate for Payer: PHP Medicare Advantage |
$124.00
|
| Rate for Payer: Priority Health Choice Medicaid |
$64.85
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$401.00
|
| Rate for Payer: Priority Health Medicare |
$124.00
|
| Rate for Payer: Priority Health SBD |
$216.21
|
| Rate for Payer: Priority Health Tiered Network |
$320.80
|
| Rate for Payer: Railroad Medicare Medicare |
$124.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$209.78
|
| Rate for Payer: UHC Core |
$209.78
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$124.00
|
| Rate for Payer: UHC Exchange |
$209.78
|
| Rate for Payer: UHC Medicaid |
$64.85
|
| Rate for Payer: UHCCP Medicaid |
$64.85
|
| Rate for Payer: VA VA |
$124.00
|
|
|
HC GRAFIX PRIME 3 X 4 PER SQ CM
|
Facility
|
OP
|
$283.54
|
|
|
Service Code
|
HCPCS Q4133
|
| Hospital Charge Code |
63600161
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$64.85 |
| Max. Negotiated Rate |
$611.41 |
| Rate for Payer: Aetna Commercial |
$241.01
|
| Rate for Payer: Aetna Medicare |
$128.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$184.30
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$155.00
|
| Rate for Payer: Amish Plain Church Group Commercial |
$155.00
|
| Rate for Payer: BCBS Complete |
$68.10
|
| Rate for Payer: BCBS MAPPO |
$124.00
|
| Rate for Payer: BCBS Trust/PPO |
$204.72
|
| Rate for Payer: BCN Commercial |
$611.41
|
| Rate for Payer: BCN Medicare Advantage |
$124.00
|
| Rate for Payer: Cash Price |
$226.83
|
| Rate for Payer: Cash Price |
$226.83
|
| Rate for Payer: Cash Price |
$226.83
|
| Rate for Payer: Cofinity Advantage |
$198.48
|
| Rate for Payer: Cofinity Commercial |
$243.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$226.83
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$124.00
|
| Rate for Payer: Healthscope Commercial |
$255.19
|
| Rate for Payer: Mclaren Medicaid |
$64.85
|
| Rate for Payer: Mclaren Medicare |
$124.00
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$130.20
|
| Rate for Payer: Meridian Medicaid |
$130.20
|
| Rate for Payer: MI Amish Medical Board Commercial |
$142.60
|
| Rate for Payer: Molina Medicare/Medicaid |
$136.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$241.01
|
| Rate for Payer: Nomi Health Commercial |
$372.00
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$212.66
|
| Rate for Payer: PACE Medicare |
$117.80
|
| Rate for Payer: PACE SWMI |
$124.00
|
| Rate for Payer: PHP Commercial |
$241.01
|
| Rate for Payer: PHP Medicare Advantage |
$124.00
|
| Rate for Payer: Priority Health Choice Medicaid |
$64.85
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$401.00
|
| Rate for Payer: Priority Health Medicare |
$124.00
|
| Rate for Payer: Priority Health SBD |
$178.63
|
| Rate for Payer: Priority Health Tiered Network |
$320.80
|
| Rate for Payer: Railroad Medicare Medicare |
$124.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$209.78
|
| Rate for Payer: UHC Core |
$209.78
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$124.00
|
| Rate for Payer: UHC Exchange |
$209.78
|
| Rate for Payer: UHC Medicaid |
$64.85
|
| Rate for Payer: UHCCP Medicaid |
$64.85
|
| Rate for Payer: VA VA |
$124.00
|
|
|
HC GRAFIX PRIME 3 X 4 PER SQ CM
|
Facility
|
IP
|
$283.54
|
|
|
Service Code
|
HCPCS Q4133
|
| Hospital Charge Code |
63600161
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$178.63 |
| Max. Negotiated Rate |
$255.19 |
| Rate for Payer: Aetna Commercial |
$241.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$184.30
|
| Rate for Payer: Cash Price |
$226.83
|
| Rate for Payer: Cofinity Advantage |
$198.48
|
| Rate for Payer: Cofinity Commercial |
$243.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$226.83
|
| Rate for Payer: Healthscope Commercial |
$255.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$241.01
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$212.66
|
| Rate for Payer: PHP Commercial |
$241.01
|
| Rate for Payer: Priority Health SBD |
$178.63
|
|
