|
HC ORCHARD GRASS IGE
|
Facility
|
OP
|
$25.90
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
30200052
|
|
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 ORGANIC ACIDS SCREEN URINE
|
Facility
|
OP
|
$76.99
|
|
|
Service Code
|
CPT 83918
|
| Hospital Charge Code |
30100372
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$12.34 |
| Max. Negotiated Rate |
$69.29 |
| Rate for Payer: Aetna Commercial |
$65.44
|
| Rate for Payer: Aetna Medicare |
$24.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$50.04
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$29.50
|
| Rate for Payer: Amish Plain Church Group Commercial |
$29.50
|
| Rate for Payer: BCBS Complete |
$12.96
|
| Rate for Payer: BCBS MAPPO |
$23.60
|
| Rate for Payer: BCBS Trust/PPO |
$25.16
|
| Rate for Payer: BCN Commercial |
$25.16
|
| Rate for Payer: BCN Medicare Advantage |
$23.60
|
| Rate for Payer: Cash Price |
$61.59
|
| Rate for Payer: Cash Price |
$61.59
|
| Rate for Payer: Cofinity Advantage |
$53.89
|
| Rate for Payer: Cofinity Commercial |
$66.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$61.59
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$23.60
|
| Rate for Payer: Healthscope Commercial |
$69.29
|
| Rate for Payer: Mclaren Medicaid |
$12.34
|
| Rate for Payer: Mclaren Medicare |
$23.60
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$24.78
|
| Rate for Payer: Meridian Medicaid |
$24.78
|
| Rate for Payer: MI Amish Medical Board Commercial |
$27.14
|
| Rate for Payer: Molina Medicare/Medicaid |
$25.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$65.44
|
| Rate for Payer: Nomi Health Commercial |
$35.40
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$57.74
|
| Rate for Payer: PACE Medicare |
$22.42
|
| Rate for Payer: PACE SWMI |
$23.60
|
| Rate for Payer: PHP Commercial |
$65.44
|
| Rate for Payer: PHP Medicare Advantage |
$23.60
|
| Rate for Payer: Priority Health Choice Medicaid |
$12.34
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$23.60
|
| Rate for Payer: Priority Health Medicare |
$23.60
|
| Rate for Payer: Priority Health SBD |
$48.50
|
| Rate for Payer: Priority Health Tiered Network |
$18.88
|
| Rate for Payer: Railroad Medicare Medicare |
$23.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$35.40
|
| Rate for Payer: UHC Core |
$35.40
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$23.60
|
| Rate for Payer: UHC Exchange |
$35.40
|
| Rate for Payer: UHC Medicaid |
$12.34
|
| Rate for Payer: UHCCP Medicaid |
$12.34
|
| Rate for Payer: VA VA |
$23.60
|
|
|
HC ORGANIC ACIDS SCREEN URINE
|
Facility
|
IP
|
$76.99
|
|
|
Service Code
|
CPT 83918
|
| Hospital Charge Code |
30100372
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$48.50 |
| Max. Negotiated Rate |
$69.29 |
| Rate for Payer: Aetna Commercial |
$65.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$50.04
|
| Rate for Payer: Cash Price |
$61.59
|
| Rate for Payer: Cofinity Advantage |
$53.89
|
| Rate for Payer: Cofinity Commercial |
$66.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$61.59
|
| Rate for Payer: Healthscope Commercial |
$69.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$65.44
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$57.74
|
| Rate for Payer: PHP Commercial |
$65.44
|
| Rate for Payer: Priority Health SBD |
$48.50
|
|
|
HC OR LEVEL 1 BASE CHARGE
|
Facility
|
OP
|
$219.00
|
|
| Hospital Charge Code |
36000126
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$87.60 |
| Max. Negotiated Rate |
$197.10 |
| Rate for Payer: Aetna Commercial |
$186.15
|
| Rate for Payer: Aetna Medicare |
$109.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$142.35
|
| Rate for Payer: BCBS Complete |
$87.60
|
| Rate for Payer: Cash Price |
$175.20
|
| Rate for Payer: Cofinity Advantage |
$153.30
|
| Rate for Payer: Cofinity Commercial |
$188.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$175.20
|
| Rate for Payer: Healthscope Commercial |
$197.10
|
| Rate for Payer: MI Amish Medical Board Commercial |
$175.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$186.15
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$164.25
|
| Rate for Payer: PHP Commercial |
$186.15
|
| Rate for Payer: Priority Health SBD |
$137.97
|
|
|
HC OR LEVEL 1 BASE CHARGE
|
Facility
|
IP
|
$219.00
|
|
| Hospital Charge Code |
36000126
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$137.97 |
| Max. Negotiated Rate |
$197.10 |
| Rate for Payer: Aetna Commercial |
$186.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$142.35
|
| Rate for Payer: Cash Price |
$175.20
|
| Rate for Payer: Cofinity Advantage |
$153.30
|
| Rate for Payer: Cofinity Commercial |
$188.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$175.20
|
| Rate for Payer: Healthscope Commercial |
$197.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$186.15
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$164.25
|
| Rate for Payer: PHP Commercial |
$186.15
|
| Rate for Payer: Priority Health SBD |
$137.97
|
|
|
HC OR LEVEL 1 PER MINUTE
|
Facility
|
IP
|
$65.00
|
|
| Hospital Charge Code |
36000127
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$40.95 |
| Max. Negotiated Rate |
$58.50 |
| Rate for Payer: Aetna Commercial |
$55.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$42.25
|
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Cofinity Advantage |
$45.50
|
| Rate for Payer: Cofinity Commercial |
$55.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$52.00
|
| Rate for Payer: Healthscope Commercial |
$58.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$55.25
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$48.75
|
| Rate for Payer: PHP Commercial |
$55.25
|
| Rate for Payer: Priority Health SBD |
$40.95
|
|
|
HC OR LEVEL 1 PER MINUTE
|
Facility
|
OP
|
$65.00
|
|
| Hospital Charge Code |
36000127
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$26.00 |
| Max. Negotiated Rate |
$58.50 |
| Rate for Payer: Aetna Commercial |
$55.25
|
| Rate for Payer: Aetna Medicare |
$32.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$42.25
|
| Rate for Payer: BCBS Complete |
$26.00
|
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Cofinity Advantage |
$45.50
|
| Rate for Payer: Cofinity Commercial |
$55.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$52.00
|
| Rate for Payer: Healthscope Commercial |
$58.50
|
| Rate for Payer: MI Amish Medical Board Commercial |
$52.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$55.25
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$48.75
|
| Rate for Payer: PHP Commercial |
$55.25
|
| Rate for Payer: Priority Health SBD |
$40.95
|
|
|
HC OR LEVEL 2 BASE CHARGE
|
Facility
|
IP
|
$643.00
|
|
| Hospital Charge Code |
36000128
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$405.09 |
| Max. Negotiated Rate |
$578.70 |
| Rate for Payer: Aetna Commercial |
$546.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$417.95
|
| Rate for Payer: Cash Price |
$514.40
|
| Rate for Payer: Cofinity Advantage |
$450.10
|
| Rate for Payer: Cofinity Commercial |
$552.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$514.40
|
| Rate for Payer: Healthscope Commercial |
$578.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$546.55
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$482.25
|
| Rate for Payer: PHP Commercial |
$546.55
|
| Rate for Payer: Priority Health SBD |
$405.09
|
|
|
HC OR LEVEL 2 BASE CHARGE
|
Facility
|
OP
|
$643.00
|
|
| Hospital Charge Code |
36000128
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$257.20 |
| Max. Negotiated Rate |
$578.70 |
| Rate for Payer: Aetna Commercial |
$546.55
|
| Rate for Payer: Aetna Medicare |
$321.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$417.95
|
| Rate for Payer: BCBS Complete |
$257.20
|
| Rate for Payer: Cash Price |
$514.40
|
| Rate for Payer: Cofinity Advantage |
$450.10
|
| Rate for Payer: Cofinity Commercial |
$552.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$514.40
|
| Rate for Payer: Healthscope Commercial |
$578.70
|
| Rate for Payer: MI Amish Medical Board Commercial |
$514.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$546.55
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$482.25
|
| Rate for Payer: PHP Commercial |
$546.55
|
| Rate for Payer: Priority Health SBD |
$405.09
|
|
|
HC OR LEVEL 2 PER MINUTE
|
Facility
|
IP
|
$97.00
|
|
| Hospital Charge Code |
36000129
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$61.11 |
| Max. Negotiated Rate |
$87.30 |
| Rate for Payer: Aetna Commercial |
$82.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$63.05
|
| Rate for Payer: Cash Price |
$77.60
|
| Rate for Payer: Cofinity Advantage |
$67.90
|
| Rate for Payer: Cofinity Commercial |
$83.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$77.60
|
| Rate for Payer: Healthscope Commercial |
$87.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$82.45
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$72.75
|
| Rate for Payer: PHP Commercial |
$82.45
|
| Rate for Payer: Priority Health SBD |
$61.11
|
|
|
HC OR LEVEL 2 PER MINUTE
|
Facility
|
OP
|
$97.00
|
|
| Hospital Charge Code |
36000129
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$38.80 |
| Max. Negotiated Rate |
$87.30 |
| Rate for Payer: Aetna Commercial |
$82.45
|
| Rate for Payer: Aetna Medicare |
$48.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$63.05
|
| Rate for Payer: BCBS Complete |
$38.80
|
| Rate for Payer: Cash Price |
$77.60
|
| Rate for Payer: Cofinity Advantage |
$67.90
|
| Rate for Payer: Cofinity Commercial |
$83.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$77.60
|
| Rate for Payer: Healthscope Commercial |
$87.30
|
| Rate for Payer: MI Amish Medical Board Commercial |
$77.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$82.45
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$72.75
|
| Rate for Payer: PHP Commercial |
$82.45
|
| Rate for Payer: Priority Health SBD |
$61.11
|
|
|
HC OR LEVEL 3 BASE CHARGE
|
Facility
|
IP
|
$857.00
|
|
| Hospital Charge Code |
36000130
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$539.91 |
| Max. Negotiated Rate |
$771.30 |
| Rate for Payer: Aetna Commercial |
$728.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$557.05
|
| Rate for Payer: Cash Price |
$685.60
|
| Rate for Payer: Cofinity Advantage |
$599.90
|
| Rate for Payer: Cofinity Commercial |
$737.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$685.60
|
| Rate for Payer: Healthscope Commercial |
$771.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$728.45
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$642.75
|
| Rate for Payer: PHP Commercial |
$728.45
|
| Rate for Payer: Priority Health SBD |
$539.91
|
|
|
HC OR LEVEL 3 BASE CHARGE
|
Facility
|
OP
|
$857.00
|
|
| Hospital Charge Code |
36000130
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$342.80 |
| Max. Negotiated Rate |
$771.30 |
| Rate for Payer: Aetna Commercial |
$728.45
|
| Rate for Payer: Aetna Medicare |
$428.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$557.05
|
| Rate for Payer: BCBS Complete |
$342.80
|
| Rate for Payer: Cash Price |
$685.60
|
| Rate for Payer: Cofinity Advantage |
$599.90
|
| Rate for Payer: Cofinity Commercial |
$737.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$685.60
|
| Rate for Payer: Healthscope Commercial |
$771.30
|
| Rate for Payer: MI Amish Medical Board Commercial |
$685.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$728.45
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$642.75
|
| Rate for Payer: PHP Commercial |
$728.45
|
| Rate for Payer: Priority Health SBD |
$539.91
|
|
|
HC OR LEVEL 3 PER MINUTE
|
Facility
|
OP
|
$108.00
|
|
| Hospital Charge Code |
36000131
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$43.20 |
| Max. Negotiated Rate |
$97.20 |
| Rate for Payer: Aetna Commercial |
$91.80
|
| Rate for Payer: Aetna Medicare |
$54.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$70.20
|
| Rate for Payer: BCBS Complete |
$43.20
|
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Cofinity Advantage |
$75.60
|
| Rate for Payer: Cofinity Commercial |
$92.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$86.40
|
| Rate for Payer: Healthscope Commercial |
$97.20
|
| Rate for Payer: MI Amish Medical Board Commercial |
$86.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$91.80
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$81.00
|
| Rate for Payer: PHP Commercial |
$91.80
|
| Rate for Payer: Priority Health SBD |
$68.04
|
|
|
HC OR LEVEL 3 PER MINUTE
|
Facility
|
IP
|
$108.00
|
|
| Hospital Charge Code |
36000131
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$68.04 |
| Max. Negotiated Rate |
$97.20 |
| Rate for Payer: Aetna Commercial |
$91.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$70.20
|
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Cofinity Advantage |
$75.60
|
| Rate for Payer: Cofinity Commercial |
$92.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$86.40
|
| Rate for Payer: Healthscope Commercial |
$97.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$91.80
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$81.00
|
| Rate for Payer: PHP Commercial |
$91.80
|
| Rate for Payer: Priority Health SBD |
$68.04
|
|
|
HC OR LEVEL 4 BASE CHARGE
|
Facility
|
IP
|
$1,372.00
|
|
| Hospital Charge Code |
36000132
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$864.36 |
| Max. Negotiated Rate |
$1,234.80 |
| Rate for Payer: Aetna Commercial |
$1,166.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$891.80
|
| Rate for Payer: Cash Price |
$1,097.60
|
| Rate for Payer: Cofinity Advantage |
$960.40
|
| Rate for Payer: Cofinity Commercial |
$1,179.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,097.60
|
| Rate for Payer: Healthscope Commercial |
$1,234.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,166.20
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,029.00
|
| Rate for Payer: PHP Commercial |
$1,166.20
|
| Rate for Payer: Priority Health SBD |
$864.36
|
|
|
HC OR LEVEL 4 BASE CHARGE
|
Facility
|
OP
|
$1,372.00
|
|
| Hospital Charge Code |
36000132
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$548.80 |
| Max. Negotiated Rate |
$1,234.80 |
| Rate for Payer: Aetna Commercial |
$1,166.20
|
| Rate for Payer: Aetna Medicare |
$686.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$891.80
|
| Rate for Payer: BCBS Complete |
$548.80
|
| Rate for Payer: Cash Price |
$1,097.60
|
| Rate for Payer: Cofinity Advantage |
$960.40
|
| Rate for Payer: Cofinity Commercial |
$1,179.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,097.60
|
| Rate for Payer: Healthscope Commercial |
$1,234.80
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,097.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,166.20
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,029.00
|
| Rate for Payer: PHP Commercial |
$1,166.20
|
| Rate for Payer: Priority Health SBD |
$864.36
|
|
|
HC OR LEVEL 4 PER MINUTE
|
Facility
|
IP
|
$118.00
|
|
| Hospital Charge Code |
36000133
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$74.34 |
| Max. Negotiated Rate |
$106.20 |
| Rate for Payer: Aetna Commercial |
$100.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$76.70
|
| Rate for Payer: Cash Price |
$94.40
|
| Rate for Payer: Cofinity Advantage |
$82.60
|
| Rate for Payer: Cofinity Commercial |
$101.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$94.40
|
| Rate for Payer: Healthscope Commercial |
$106.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$100.30
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$88.50
|
| Rate for Payer: PHP Commercial |
$100.30
|
| Rate for Payer: Priority Health SBD |
$74.34
|
|
|
HC OR LEVEL 4 PER MINUTE
|
Facility
|
OP
|
$118.00
|
|
| Hospital Charge Code |
36000133
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$47.20 |
| Max. Negotiated Rate |
$106.20 |
| Rate for Payer: Aetna Commercial |
$100.30
|
| Rate for Payer: Aetna Medicare |
$59.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$76.70
|
| Rate for Payer: BCBS Complete |
$47.20
|
| Rate for Payer: Cash Price |
$94.40
|
| Rate for Payer: Cofinity Advantage |
$82.60
|
| Rate for Payer: Cofinity Commercial |
$101.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$94.40
|
| Rate for Payer: Healthscope Commercial |
$106.20
|
| Rate for Payer: MI Amish Medical Board Commercial |
$94.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$100.30
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$88.50
|
| Rate for Payer: PHP Commercial |
$100.30
|
| Rate for Payer: Priority Health SBD |
$74.34
|
|
|
HC OR LEVEL 5 BASE CHARGE
|
Facility
|
OP
|
$2,188.00
|
|
| Hospital Charge Code |
36000134
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$875.20 |
| Max. Negotiated Rate |
$1,969.20 |
| Rate for Payer: Aetna Commercial |
$1,859.80
|
| Rate for Payer: Aetna Medicare |
$1,094.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,422.20
|
| Rate for Payer: BCBS Complete |
$875.20
|
| Rate for Payer: Cash Price |
$1,750.40
|
| Rate for Payer: Cofinity Advantage |
$1,531.60
|
| Rate for Payer: Cofinity Commercial |
$1,881.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,750.40
|
| Rate for Payer: Healthscope Commercial |
$1,969.20
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,750.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,859.80
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,641.00
|
| Rate for Payer: PHP Commercial |
$1,859.80
|
| Rate for Payer: Priority Health SBD |
$1,378.44
|
|
|
HC OR LEVEL 5 BASE CHARGE
|
Facility
|
IP
|
$2,188.00
|
|
| Hospital Charge Code |
36000134
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,378.44 |
| Max. Negotiated Rate |
$1,969.20 |
| Rate for Payer: Aetna Commercial |
$1,859.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,422.20
|
| Rate for Payer: Cash Price |
$1,750.40
|
| Rate for Payer: Cofinity Advantage |
$1,531.60
|
| Rate for Payer: Cofinity Commercial |
$1,881.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,750.40
|
| Rate for Payer: Healthscope Commercial |
$1,969.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,859.80
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,641.00
|
| Rate for Payer: PHP Commercial |
$1,859.80
|
| Rate for Payer: Priority Health SBD |
$1,378.44
|
|
|
HC OR LEVEL 5 PER MINUTE
|
Facility
|
IP
|
$150.00
|
|
| Hospital Charge Code |
36000135
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$94.50 |
| Max. Negotiated Rate |
$135.00 |
| Rate for Payer: Aetna Commercial |
$127.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$97.50
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Cofinity Advantage |
$105.00
|
| Rate for Payer: Cofinity Commercial |
$129.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$120.00
|
| Rate for Payer: Healthscope Commercial |
$135.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$127.50
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$112.50
|
| Rate for Payer: PHP Commercial |
$127.50
|
| Rate for Payer: Priority Health SBD |
$94.50
|
|
|
HC OR LEVEL 5 PER MINUTE
|
Facility
|
OP
|
$150.00
|
|
| Hospital Charge Code |
36000135
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$60.00 |
| Max. Negotiated Rate |
$135.00 |
| Rate for Payer: Aetna Commercial |
$127.50
|
| Rate for Payer: Aetna Medicare |
$75.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$97.50
|
| Rate for Payer: BCBS Complete |
$60.00
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Cofinity Advantage |
$105.00
|
| Rate for Payer: Cofinity Commercial |
$129.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$120.00
|
| Rate for Payer: Healthscope Commercial |
$135.00
|
| Rate for Payer: MI Amish Medical Board Commercial |
$120.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$127.50
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$112.50
|
| Rate for Payer: PHP Commercial |
$127.50
|
| Rate for Payer: Priority Health SBD |
$94.50
|
|
|
HC ORPHENADRINE INJECTION, PER 60MG
|
Facility
|
IP
|
$30.77
|
|
|
Service Code
|
HCPCS J2360
|
| Hospital Charge Code |
63600143
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.39 |
| Max. Negotiated Rate |
$27.69 |
| Rate for Payer: Aetna Commercial |
$26.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$20.00
|
| Rate for Payer: Cash Price |
$24.62
|
| Rate for Payer: Cofinity Advantage |
$21.54
|
| Rate for Payer: Cofinity Commercial |
$26.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$24.62
|
| Rate for Payer: Healthscope Commercial |
$27.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$26.15
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$23.08
|
| Rate for Payer: PHP Commercial |
$26.15
|
| Rate for Payer: Priority Health SBD |
$19.39
|
|
|
HC ORPHENADRINE INJECTION, PER 60MG
|
Facility
|
OP
|
$30.77
|
|
|
Service Code
|
HCPCS J2360
|
| Hospital Charge Code |
63600143
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.54 |
| Max. Negotiated Rate |
$27.69 |
| Rate for Payer: Aetna Commercial |
$26.15
|
| Rate for Payer: Aetna Medicare |
$15.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$20.00
|
| Rate for Payer: BCBS Complete |
$12.31
|
| Rate for Payer: BCBS Trust/PPO |
$16.03
|
| Rate for Payer: BCN Commercial |
$16.03
|
| Rate for Payer: Cash Price |
$24.62
|
| Rate for Payer: Cash Price |
$24.62
|
| Rate for Payer: Cofinity Advantage |
$21.54
|
| Rate for Payer: Cofinity Commercial |
$26.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$24.62
|
| Rate for Payer: Healthscope Commercial |
$27.69
|
| Rate for Payer: MI Amish Medical Board Commercial |
$24.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$26.15
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$23.08
|
| Rate for Payer: PHP Commercial |
$26.15
|
| Rate for Payer: Priority Health SBD |
$19.39
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$10.54
|
| Rate for Payer: UHC Core |
$10.54
|
| Rate for Payer: UHC Exchange |
$10.54
|
|
