|
CHG VENOGRAPHY ADRENAL UNILATERAL SELECTIVE RS&I
|
Professional
|
Both
|
$286.00
|
|
|
Service Code
|
HCPCS 75840
|
| Min. Negotiated Rate |
$114.40 |
| Max. Negotiated Rate |
$311.17 |
| Rate for Payer: Aetna Commercial |
$165.72
|
| Rate for Payer: Aetna Medicare |
$128.62
|
| Rate for Payer: BCBS Complete |
$114.40
|
| Rate for Payer: BCBS MAPPO |
$123.67
|
| Rate for Payer: BCBS Trust/PPO |
$311.17
|
| Rate for Payer: BCN Commercial |
$189.61
|
| Rate for Payer: BCN Medicare Advantage |
$123.67
|
| Rate for Payer: Cash Price |
$228.80
|
| Rate for Payer: Cash Price |
$228.80
|
| Rate for Payer: Cofinity Commercial |
$178.08
|
| Rate for Payer: Cofinity Commercial |
$165.72
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$123.67
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$129.85
|
| Rate for Payer: PACE SWMI |
$123.67
|
| Rate for Payer: PHP Medicare Advantage |
$123.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$200.20
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$198.72
|
| Rate for Payer: Priority Health Medicare |
$123.67
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$198.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$123.67
|
| Rate for Payer: UHC Dual Complete DSNP |
$123.67
|
| Rate for Payer: UHC Medicare Advantage |
$127.38
|
|
|
CHG VENOGRAPHY CAVAL INFERIOR SERIALOGRAPHY RS&I
|
Professional
|
Both
|
$106.00
|
|
|
Service Code
|
HCPCS 75825
|
| Min. Negotiated Rate |
$42.40 |
| Max. Negotiated Rate |
$238.26 |
| Rate for Payer: Aetna Commercial |
$147.21
|
| Rate for Payer: Aetna Medicare |
$114.25
|
| Rate for Payer: BCBS Complete |
$42.40
|
| Rate for Payer: BCBS MAPPO |
$109.86
|
| Rate for Payer: BCBS Trust/PPO |
$238.26
|
| Rate for Payer: BCN Commercial |
$167.13
|
| Rate for Payer: BCN Medicare Advantage |
$109.86
|
| Rate for Payer: Cash Price |
$84.80
|
| Rate for Payer: Cash Price |
$84.80
|
| Rate for Payer: Cofinity Commercial |
$147.21
|
| Rate for Payer: Cofinity Commercial |
$158.20
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$109.86
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$115.35
|
| Rate for Payer: PACE SWMI |
$109.86
|
| Rate for Payer: PHP Medicare Advantage |
$109.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$74.20
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$175.15
|
| Rate for Payer: Priority Health Medicare |
$109.86
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$175.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$109.86
|
| Rate for Payer: UHC Dual Complete DSNP |
$109.86
|
| Rate for Payer: UHC Medicare Advantage |
$113.16
|
|
|
CHG VENOGRAPHY CAVAL SUPERIOR SERIALOGRAPHY RS&I
|
Professional
|
Both
|
$103.00
|
|
|
Service Code
|
HCPCS 75827
|
| Min. Negotiated Rate |
$41.20 |
| Max. Negotiated Rate |
$307.47 |
| Rate for Payer: Aetna Commercial |
$153.83
|
| Rate for Payer: Aetna Medicare |
$119.39
|
| Rate for Payer: BCBS Complete |
$41.20
|
| Rate for Payer: BCBS MAPPO |
$114.80
|
| Rate for Payer: BCBS Trust/PPO |
$307.47
|
| Rate for Payer: BCN Commercial |
$174.95
|
| Rate for Payer: BCN Medicare Advantage |
$114.80
|
| Rate for Payer: Cash Price |
$82.40
|
| Rate for Payer: Cash Price |
$82.40
|
| Rate for Payer: Cofinity Commercial |
$153.83
|
| Rate for Payer: Cofinity Commercial |
$165.31
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$114.80
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$120.54
|
| Rate for Payer: PACE SWMI |
$114.80
|
| Rate for Payer: PHP Medicare Advantage |
$114.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$72.10
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$183.36
|
| Rate for Payer: Priority Health Medicare |
$114.80
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$183.36
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$114.80
|
| Rate for Payer: UHC Dual Complete DSNP |
$114.80
|
| Rate for Payer: UHC Medicare Advantage |
$118.24
|
|
|
CHG VENOGRAPHY EXTREMITY BILATERAL RS&I
|
Professional
|
Both
|
$269.00
|
|
|
Service Code
|
HCPCS 75822
|
| Min. Negotiated Rate |
$107.60 |
| Max. Negotiated Rate |
$265.21 |
| Rate for Payer: Aetna Commercial |
$171.60
|
| Rate for Payer: Aetna Commercial |
$171.60
|
| Rate for Payer: Aetna Medicare |
$133.18
|
| Rate for Payer: Aetna Medicare |
$133.18
|
| Rate for Payer: BCBS Complete |
$55.60
|
| Rate for Payer: BCBS Complete |
$107.60
|
| Rate for Payer: BCBS MAPPO |
$128.06
|
| Rate for Payer: BCBS MAPPO |
$128.06
|
| Rate for Payer: BCBS Trust/PPO |
$265.21
|
| Rate for Payer: BCBS Trust/PPO |
$265.21
|
| Rate for Payer: BCN Commercial |
$194.49
|
| Rate for Payer: BCN Commercial |
$194.49
|
| Rate for Payer: BCN Medicare Advantage |
$128.06
|
| Rate for Payer: BCN Medicare Advantage |
$128.06
|
| Rate for Payer: Cash Price |
$215.20
|
| Rate for Payer: Cash Price |
$111.20
|
| Rate for Payer: Cash Price |
$111.20
|
| Rate for Payer: Cash Price |
$215.20
|
| Rate for Payer: Cofinity Commercial |
$184.41
|
| Rate for Payer: Cofinity Commercial |
$171.60
|
| Rate for Payer: Cofinity Commercial |
$184.41
|
| Rate for Payer: Cofinity Commercial |
$171.60
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$128.06
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$128.06
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$134.46
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$134.46
|
| Rate for Payer: PACE SWMI |
$128.06
|
| Rate for Payer: PACE SWMI |
$128.06
|
| Rate for Payer: PHP Medicare Advantage |
$128.06
|
| Rate for Payer: PHP Medicare Advantage |
$128.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$188.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$97.30
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$203.84
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$203.84
|
| Rate for Payer: Priority Health Medicare |
$128.06
|
| Rate for Payer: Priority Health Medicare |
$128.06
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$203.84
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$203.84
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$128.06
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$128.06
|
| Rate for Payer: UHC Dual Complete DSNP |
$128.06
|
| Rate for Payer: UHC Dual Complete DSNP |
$128.06
|
| Rate for Payer: UHC Medicare Advantage |
$131.90
|
| Rate for Payer: UHC Medicare Advantage |
$131.90
|
|
|
CHG VENOGRAPHY EXTREMITY UNILATERAL RS&I
|
Professional
|
Both
|
$124.00
|
|
|
Service Code
|
HCPCS 75820
|
| Min. Negotiated Rate |
$49.60 |
| Max. Negotiated Rate |
$191.77 |
| Rate for Payer: Aetna Commercial |
$140.19
|
| Rate for Payer: Aetna Medicare |
$108.80
|
| Rate for Payer: BCBS Complete |
$49.60
|
| Rate for Payer: BCBS MAPPO |
$104.62
|
| Rate for Payer: BCBS Trust/PPO |
$191.77
|
| Rate for Payer: BCN Commercial |
$159.79
|
| Rate for Payer: BCN Medicare Advantage |
$104.62
|
| Rate for Payer: Cash Price |
$99.20
|
| Rate for Payer: Cash Price |
$99.20
|
| Rate for Payer: Cofinity Commercial |
$140.19
|
| Rate for Payer: Cofinity Commercial |
$150.65
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$104.62
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$109.85
|
| Rate for Payer: PACE SWMI |
$104.62
|
| Rate for Payer: PHP Medicare Advantage |
$104.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$86.80
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$167.48
|
| Rate for Payer: Priority Health Medicare |
$104.62
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$167.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$104.62
|
| Rate for Payer: UHC Dual Complete DSNP |
$104.62
|
| Rate for Payer: UHC Medicare Advantage |
$107.76
|
|
|
CHG VENOGRAPHY RENAL BILATERAL SELECTIVE RS&I
|
Professional
|
Both
|
$136.00
|
|
|
Service Code
|
HCPCS 75833
|
| Min. Negotiated Rate |
$54.40 |
| Max. Negotiated Rate |
$369.81 |
| Rate for Payer: Aetna Commercial |
$189.54
|
| Rate for Payer: Aetna Medicare |
$147.11
|
| Rate for Payer: BCBS Complete |
$54.40
|
| Rate for Payer: BCBS MAPPO |
$141.45
|
| Rate for Payer: BCBS Trust/PPO |
$369.81
|
| Rate for Payer: BCN Commercial |
$215.02
|
| Rate for Payer: BCN Medicare Advantage |
$141.45
|
| Rate for Payer: Cash Price |
$108.80
|
| Rate for Payer: Cash Price |
$108.80
|
| Rate for Payer: Cofinity Commercial |
$203.69
|
| Rate for Payer: Cofinity Commercial |
$189.54
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$141.45
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$148.52
|
| Rate for Payer: PACE SWMI |
$141.45
|
| Rate for Payer: PHP Medicare Advantage |
$141.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$95.20
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$225.35
|
| Rate for Payer: Priority Health Medicare |
$141.45
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$225.35
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$141.45
|
| Rate for Payer: UHC Dual Complete DSNP |
$141.45
|
| Rate for Payer: UHC Medicare Advantage |
$145.69
|
|
|
CHG VENOGRAPHY RENAL UNILATERAL SELECTIVE RS&I
|
Professional
|
Both
|
$268.00
|
|
|
Service Code
|
HCPCS 75831
|
| Min. Negotiated Rate |
$107.20 |
| Max. Negotiated Rate |
$187.60 |
| Rate for Payer: Aetna Commercial |
$154.84
|
| Rate for Payer: Aetna Commercial |
$154.84
|
| Rate for Payer: Aetna Medicare |
$120.17
|
| Rate for Payer: Aetna Medicare |
$120.17
|
| Rate for Payer: BCBS Complete |
$107.20
|
| Rate for Payer: BCBS Complete |
$43.60
|
| Rate for Payer: BCBS MAPPO |
$115.55
|
| Rate for Payer: BCBS MAPPO |
$115.55
|
| Rate for Payer: BCBS Trust/PPO |
$156.38
|
| Rate for Payer: BCBS Trust/PPO |
$156.38
|
| Rate for Payer: BCN Commercial |
$176.42
|
| Rate for Payer: BCN Commercial |
$176.42
|
| Rate for Payer: BCN Medicare Advantage |
$115.55
|
| Rate for Payer: BCN Medicare Advantage |
$115.55
|
| Rate for Payer: Cash Price |
$214.40
|
| Rate for Payer: Cash Price |
$214.40
|
| Rate for Payer: Cash Price |
$87.20
|
| Rate for Payer: Cash Price |
$87.20
|
| Rate for Payer: Cofinity Commercial |
$154.84
|
| Rate for Payer: Cofinity Commercial |
$166.39
|
| Rate for Payer: Cofinity Commercial |
$154.84
|
| Rate for Payer: Cofinity Commercial |
$166.39
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$115.55
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$115.55
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$121.33
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$121.33
|
| Rate for Payer: PACE SWMI |
$115.55
|
| Rate for Payer: PACE SWMI |
$115.55
|
| Rate for Payer: PHP Medicare Advantage |
$115.55
|
| Rate for Payer: PHP Medicare Advantage |
$115.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$187.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$76.30
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$184.89
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$184.89
|
| Rate for Payer: Priority Health Medicare |
$115.55
|
| Rate for Payer: Priority Health Medicare |
$115.55
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$184.89
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$184.89
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$115.55
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$115.55
|
| Rate for Payer: UHC Dual Complete DSNP |
$115.55
|
| Rate for Payer: UHC Dual Complete DSNP |
$115.55
|
| Rate for Payer: UHC Medicare Advantage |
$119.02
|
| Rate for Payer: UHC Medicare Advantage |
$119.02
|
|
|
CHG VENOGRAPHY VENOUS SINUS/JUGULAR CATH RS&I
|
Professional
|
Both
|
$359.00
|
|
|
Service Code
|
HCPCS 75860
|
| Min. Negotiated Rate |
$120.80 |
| Max. Negotiated Rate |
$310.64 |
| Rate for Payer: Aetna Commercial |
$161.87
|
| Rate for Payer: Aetna Commercial |
$161.87
|
| Rate for Payer: Aetna Medicare |
$125.63
|
| Rate for Payer: Aetna Medicare |
$125.63
|
| Rate for Payer: BCBS Complete |
$143.60
|
| Rate for Payer: BCBS Complete |
$110.00
|
| Rate for Payer: BCBS MAPPO |
$120.80
|
| Rate for Payer: BCBS MAPPO |
$120.80
|
| Rate for Payer: BCBS Trust/PPO |
$310.64
|
| Rate for Payer: BCBS Trust/PPO |
$310.64
|
| Rate for Payer: BCN Commercial |
$184.72
|
| Rate for Payer: BCN Commercial |
$184.72
|
| Rate for Payer: BCN Medicare Advantage |
$120.80
|
| Rate for Payer: BCN Medicare Advantage |
$120.80
|
| Rate for Payer: Cash Price |
$287.20
|
| Rate for Payer: Cash Price |
$287.20
|
| Rate for Payer: Cash Price |
$220.00
|
| Rate for Payer: Cash Price |
$220.00
|
| Rate for Payer: Cofinity Commercial |
$161.87
|
| Rate for Payer: Cofinity Commercial |
$173.95
|
| Rate for Payer: Cofinity Commercial |
$173.95
|
| Rate for Payer: Cofinity Commercial |
$161.87
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$120.80
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$120.80
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$126.84
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$126.84
|
| Rate for Payer: PACE SWMI |
$120.80
|
| Rate for Payer: PACE SWMI |
$120.80
|
| Rate for Payer: PHP Medicare Advantage |
$120.80
|
| Rate for Payer: PHP Medicare Advantage |
$120.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$251.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$192.50
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$193.59
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$193.59
|
| Rate for Payer: Priority Health Medicare |
$120.80
|
| Rate for Payer: Priority Health Medicare |
$120.80
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$193.59
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$193.59
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$120.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$120.80
|
| Rate for Payer: UHC Dual Complete DSNP |
$120.80
|
| Rate for Payer: UHC Dual Complete DSNP |
$120.80
|
| Rate for Payer: UHC Medicare Advantage |
$124.42
|
| Rate for Payer: UHC Medicare Advantage |
$124.42
|
|
|
CHG VENOUS SAMPLING THRU CATH W/WO ANGIOGRAPHY RS&
|
Professional
|
Both
|
$327.00
|
|
|
Service Code
|
HCPCS 75893
|
| Min. Negotiated Rate |
$97.97 |
| Max. Negotiated Rate |
$353.43 |
| Rate for Payer: Aetna Commercial |
$131.28
|
| Rate for Payer: Aetna Medicare |
$101.89
|
| Rate for Payer: BCBS Complete |
$130.80
|
| Rate for Payer: BCBS MAPPO |
$97.97
|
| Rate for Payer: BCBS Trust/PPO |
$353.43
|
| Rate for Payer: BCN Commercial |
$151.98
|
| Rate for Payer: BCN Medicare Advantage |
$97.97
|
| Rate for Payer: Cash Price |
$261.60
|
| Rate for Payer: Cash Price |
$261.60
|
| Rate for Payer: Cofinity Commercial |
$131.28
|
| Rate for Payer: Cofinity Commercial |
$141.08
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$97.97
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$102.87
|
| Rate for Payer: PACE SWMI |
$97.97
|
| Rate for Payer: PHP Medicare Advantage |
$97.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$228.90
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$159.29
|
| Rate for Payer: Priority Health Medicare |
$97.97
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$159.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$97.97
|
| Rate for Payer: UHC Dual Complete DSNP |
$97.97
|
| Rate for Payer: UHC Medicare Advantage |
$100.91
|
|
|
CHG X-RAY ABDOMEN 1 VW
|
Professional
|
Both
|
$30.00
|
|
|
Service Code
|
HCPCS 74000
|
| Min. Negotiated Rate |
$12.00 |
| Max. Negotiated Rate |
$21.00 |
| Rate for Payer: BCBS Complete |
$12.00
|
| Rate for Payer: BCBS Complete |
$14.00
|
| Rate for Payer: Cash Price |
$28.00
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.50
|
|
|
CHG X-RAY ABDOMEN 2 VW
|
Professional
|
Both
|
$52.00
|
|
|
Service Code
|
HCPCS 74020
|
| Min. Negotiated Rate |
$20.80 |
| Max. Negotiated Rate |
$36.40 |
| Rate for Payer: BCBS Complete |
$20.80
|
| Rate for Payer: Cash Price |
$41.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$36.40
|
|
|
CHG X-RAY FEMUR 2 VW
|
Professional
|
Both
|
$37.00
|
|
|
Service Code
|
HCPCS 73550
|
| Min. Negotiated Rate |
$14.80 |
| Max. Negotiated Rate |
$25.90 |
| Rate for Payer: BCBS Complete |
$14.80
|
| Rate for Payer: BCBS Complete |
$36.80
|
| Rate for Payer: BCBS Complete |
$11.60
|
| Rate for Payer: Cash Price |
$73.60
|
| Rate for Payer: Cash Price |
$23.20
|
| Rate for Payer: Cash Price |
$29.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$25.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$64.40
|
|
|
CHG X-RAY HIPS 4 VW + PELVIS
|
Professional
|
Both
|
$46.00
|
|
|
Service Code
|
HCPCS 73520
|
| Min. Negotiated Rate |
$18.40 |
| Max. Negotiated Rate |
$32.20 |
| Rate for Payer: BCBS Complete |
$18.40
|
| Rate for Payer: BCBS Complete |
$47.60
|
| Rate for Payer: BCBS Complete |
$21.20
|
| Rate for Payer: Cash Price |
$95.20
|
| Rate for Payer: Cash Price |
$36.80
|
| Rate for Payer: Cash Price |
$42.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$32.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$37.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$83.30
|
|
|
CHG X-RAY HIP UNI 2+ VW
|
Professional
|
Both
|
$98.00
|
|
|
Service Code
|
HCPCS 73510
|
| Min. Negotiated Rate |
$39.20 |
| Max. Negotiated Rate |
$68.60 |
| Rate for Payer: BCBS Complete |
$39.20
|
| Rate for Payer: BCBS Complete |
$14.40
|
| Rate for Payer: BCBS Complete |
$21.20
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cash Price |
$78.40
|
| Rate for Payer: Cash Price |
$42.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$25.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$37.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$68.60
|
|
|
CHG X-RAY HIP UNILAT 1 VW
|
Professional
|
Both
|
$30.00
|
|
|
Service Code
|
HCPCS 73500
|
| Min. Negotiated Rate |
$12.00 |
| Max. Negotiated Rate |
$21.00 |
| Rate for Payer: BCBS Complete |
$12.00
|
| Rate for Payer: BCBS Complete |
$39.20
|
| Rate for Payer: Cash Price |
$78.40
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$68.60
|
|
|
CHG X-RAY PELVIS/HIPS CHILD/INFANT
|
Professional
|
Both
|
$34.00
|
|
|
Service Code
|
HCPCS 73540
|
| Min. Negotiated Rate |
$13.60 |
| Max. Negotiated Rate |
$23.80 |
| Rate for Payer: BCBS Complete |
$13.60
|
| Rate for Payer: BCBS Complete |
$38.00
|
| Rate for Payer: Cash Price |
$76.00
|
| Rate for Payer: Cash Price |
$27.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$66.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$23.80
|
|
|
CHG X-RAY SPINE SURVEY
|
Professional
|
Both
|
$72.00
|
|
|
Service Code
|
HCPCS 72010
|
| Min. Negotiated Rate |
$28.80 |
| Max. Negotiated Rate |
$50.40 |
| Rate for Payer: BCBS Complete |
$28.80
|
| Rate for Payer: Cash Price |
$57.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$50.40
|
|
|
CHG X-RAY THOR-LUMB SP SCOLIOSIS
|
Professional
|
Both
|
$70.00
|
|
|
Service Code
|
HCPCS 72090
|
| Min. Negotiated Rate |
$28.00 |
| Max. Negotiated Rate |
$49.00 |
| Rate for Payer: BCBS Complete |
$28.00
|
| Rate for Payer: BCBS Complete |
$52.00
|
| Rate for Payer: BCBS Complete |
$39.20
|
| Rate for Payer: Cash Price |
$104.00
|
| Rate for Payer: Cash Price |
$78.40
|
| Rate for Payer: Cash Price |
$56.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$91.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$49.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$68.60
|
|
|
CHG X-RAY TRUNK SPINE SCOLIOSIS
|
Professional
|
Both
|
$44.00
|
|
|
Service Code
|
HCPCS 72069
|
| Min. Negotiated Rate |
$17.60 |
| Max. Negotiated Rate |
$30.80 |
| Rate for Payer: BCBS Complete |
$17.60
|
| Rate for Payer: BCBS Complete |
$23.60
|
| Rate for Payer: Cash Price |
$35.20
|
| Rate for Payer: Cash Price |
$47.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$30.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$41.30
|
|
|
CHLORDIAZEPOXIDE 10 MG CAPSULE
|
Facility
|
IP
|
$4.36
|
|
|
Service Code
|
NDC 51079-375-01
|
| Hospital Charge Code |
1622
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.66 |
| Max. Negotiated Rate |
$3.92 |
| Rate for Payer: Aetna Commercial |
$3.71
|
| Rate for Payer: BCBS Trust/PPO |
$3.37
|
| Rate for Payer: BCN Commercial |
$3.37
|
| Rate for Payer: Cash Price |
$3.49
|
| Rate for Payer: Cofinity Commercial |
$3.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.49
|
| Rate for Payer: Healthscope Commercial |
$3.92
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.71
|
| Rate for Payer: PHP Commercial |
$3.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.05
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$3.79
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.84
|
| Rate for Payer: UHC Core |
$3.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.27
|
|
|
CHLORDIAZEPOXIDE 10 MG CAPSULE
|
Facility
|
IP
|
$282.00
|
|
|
Service Code
|
NDC 0555-0033-02
|
| Hospital Charge Code |
1622
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$171.99 |
| Max. Negotiated Rate |
$253.80 |
| Rate for Payer: Aetna Commercial |
$239.70
|
| Rate for Payer: BCBS Trust/PPO |
$217.93
|
| Rate for Payer: BCN Commercial |
$217.93
|
| Rate for Payer: Cash Price |
$225.60
|
| Rate for Payer: Cofinity Commercial |
$242.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$225.60
|
| Rate for Payer: Healthscope Commercial |
$253.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$211.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$239.70
|
| Rate for Payer: PHP Commercial |
$239.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$197.40
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$245.34
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$171.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$248.16
|
| Rate for Payer: UHC Core |
$235.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$211.50
|
|
|
CHLORDIAZEPOXIDE 25 MG CAPSULE
|
Facility
|
IP
|
$345.45
|
|
|
Service Code
|
NDC 0555-0159-02
|
| Hospital Charge Code |
1623
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$210.69 |
| Max. Negotiated Rate |
$310.90 |
| Rate for Payer: Aetna Commercial |
$293.63
|
| Rate for Payer: BCBS Trust/PPO |
$266.96
|
| Rate for Payer: BCN Commercial |
$266.96
|
| Rate for Payer: Cash Price |
$276.36
|
| Rate for Payer: Cofinity Commercial |
$297.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$276.36
|
| Rate for Payer: Healthscope Commercial |
$310.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$259.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$293.63
|
| Rate for Payer: PHP Commercial |
$293.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$241.82
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$300.54
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$210.69
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$304.00
|
| Rate for Payer: UHC Core |
$288.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$259.09
|
|
|
CHLORDIAZEPOXIDE 25 MG CAPSULE
|
Facility
|
IP
|
$4.70
|
|
|
Service Code
|
NDC 51079-141-01
|
| Hospital Charge Code |
1623
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.87 |
| Max. Negotiated Rate |
$4.23 |
| Rate for Payer: Aetna Commercial |
$4.00
|
| Rate for Payer: BCBS Trust/PPO |
$3.63
|
| Rate for Payer: BCN Commercial |
$3.63
|
| Rate for Payer: Cash Price |
$3.76
|
| Rate for Payer: Cofinity Commercial |
$4.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.76
|
| Rate for Payer: Healthscope Commercial |
$4.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4.00
|
| Rate for Payer: PHP Commercial |
$4.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.29
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$4.09
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.87
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$4.14
|
| Rate for Payer: UHC Core |
$3.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.52
|
|
|
CHLORDIAZEPOXIDE 25 MG CAPSULE
|
Facility
|
IP
|
$1,527.50
|
|
|
Service Code
|
NDC 0555-0159-04
|
| Hospital Charge Code |
1623
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$931.62 |
| Max. Negotiated Rate |
$1,374.75 |
| Rate for Payer: Aetna Commercial |
$1,298.38
|
| Rate for Payer: BCBS Trust/PPO |
$1,180.45
|
| Rate for Payer: BCN Commercial |
$1,180.45
|
| Rate for Payer: Cash Price |
$1,222.00
|
| Rate for Payer: Cofinity Commercial |
$1,313.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,222.00
|
| Rate for Payer: Healthscope Commercial |
$1,374.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,145.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,298.38
|
| Rate for Payer: PHP Commercial |
$1,298.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,069.25
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,328.92
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$931.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,344.20
|
| Rate for Payer: UHC Core |
$1,275.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,145.62
|
|
|
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH
|
Facility
|
IP
|
$44.47
|
|
|
Service Code
|
NDC 0116-2001-16
|
| Hospital Charge Code |
9516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$27.12 |
| Max. Negotiated Rate |
$40.02 |
| Rate for Payer: Aetna Commercial |
$37.80
|
| Rate for Payer: BCBS Trust/PPO |
$34.37
|
| Rate for Payer: BCN Commercial |
$34.37
|
| Rate for Payer: Cash Price |
$35.58
|
| Rate for Payer: Cofinity Commercial |
$38.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$35.58
|
| Rate for Payer: Healthscope Commercial |
$40.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$33.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$37.80
|
| Rate for Payer: PHP Commercial |
$37.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$31.13
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$38.69
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$27.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$39.13
|
| Rate for Payer: UHC Core |
$37.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$33.35
|
|
