|
APPLICATION OF LONG LEG CAST (THIGH TO TOES);
|
Facility
|
OP
|
$817.84
|
|
|
Service Code
|
CPT 29345
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$95.20 |
| Max. Negotiated Rate |
$817.84 |
| Rate for Payer: Aetna Medicare |
$270.62
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$325.26
|
| Rate for Payer: Amish Plain Church Group Commercial |
$325.26
|
| Rate for Payer: BCBS Complete |
$146.45
|
| Rate for Payer: BCBS MAPPO |
$260.21
|
| Rate for Payer: BCBS Trust/PPO |
$223.09
|
| Rate for Payer: BCN Commercial |
$223.09
|
| Rate for Payer: BCN Medicare Advantage |
$260.21
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$260.21
|
| Rate for Payer: Mclaren Medicaid |
$139.47
|
| Rate for Payer: Mclaren Medicare |
$260.21
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$273.22
|
| Rate for Payer: Meridian Medicaid |
$146.45
|
| Rate for Payer: MI Amish Medical Board Commercial |
$299.24
|
| Rate for Payer: Nomi Health Commercial |
$546.44
|
| Rate for Payer: PACE Medicare |
$247.20
|
| Rate for Payer: PACE SWMI |
$260.21
|
| Rate for Payer: PHP Medicare Advantage |
$260.21
|
| Rate for Payer: Priority Health Choice Medicaid |
$139.47
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$817.84
|
| Rate for Payer: Priority Health Medicare |
$260.21
|
| Rate for Payer: Priority Health Narrow Network |
$654.27
|
| Rate for Payer: Railroad Medicare Medicare |
$260.21
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$104.72
|
| Rate for Payer: UHC Core |
$700.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$260.21
|
| Rate for Payer: UHC Exchange |
$95.20
|
| Rate for Payer: UHC Medicare Advantage |
$260.21
|
| Rate for Payer: UHCCP Medicaid |
$139.47
|
| Rate for Payer: VA VA |
$260.21
|
|
|
APPLICATION OF LOW COST SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; EACH ADDITIONAL 25 SQ CM WOUND SURFACE AREA, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$700.00
|
|
|
Service Code
|
CPT C5276
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$700.00 |
| Rate for Payer: BCBS Trust/PPO |
$0.01
|
| Rate for Payer: BCN Commercial |
$0.01
|
| Rate for Payer: UHC Core |
$700.00
|
|
|
APPLICATION OF LOW COST SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA
|
Facility
|
OP
|
$1,885.01
|
|
|
Service Code
|
CPT C5275
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$321.47 |
| Max. Negotiated Rate |
$1,885.01 |
| Rate for Payer: Aetna Medicare |
$623.74
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$749.69
|
| Rate for Payer: Amish Plain Church Group Commercial |
$749.69
|
| Rate for Payer: BCBS Complete |
$337.54
|
| Rate for Payer: BCBS MAPPO |
$599.75
|
| Rate for Payer: BCBS Trust/PPO |
$444.89
|
| Rate for Payer: BCN Commercial |
$444.89
|
| Rate for Payer: BCN Medicare Advantage |
$599.75
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$599.75
|
| Rate for Payer: Mclaren Medicaid |
$321.47
|
| Rate for Payer: Mclaren Medicare |
$599.75
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$629.74
|
| Rate for Payer: Meridian Medicaid |
$337.54
|
| Rate for Payer: MI Amish Medical Board Commercial |
$689.71
|
| Rate for Payer: Nomi Health Commercial |
$1,259.48
|
| Rate for Payer: PACE Medicare |
$569.76
|
| Rate for Payer: PACE SWMI |
$599.75
|
| Rate for Payer: PHP Medicare Advantage |
$599.75
|
| Rate for Payer: Priority Health Choice Medicaid |
$321.47
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,885.01
|
| Rate for Payer: Priority Health Medicare |
$599.75
|
| Rate for Payer: Priority Health Narrow Network |
$1,508.01
|
| Rate for Payer: Railroad Medicare Medicare |
$599.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,688.24
|
| Rate for Payer: UHC Core |
$700.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$599.75
|
| Rate for Payer: UHC Exchange |
$1,146.18
|
| Rate for Payer: UHC Medicare Advantage |
$599.75
|
| Rate for Payer: UHCCP Medicaid |
$321.47
|
| Rate for Payer: VA VA |
$599.75
|
|
|
APPLICATION OF LOW COST SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA GREATER THAN OR EQUAL TO 100 SQ CM; EACH ADDITIONAL 100 SQ CM WOUND SURFACE AREA, OR PART THEREOF, OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$700.00
|
|
|
Service Code
|
CPT C5274
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$700.00 |
| Rate for Payer: BCBS Trust/PPO |
$0.01
|
| Rate for Payer: BCN Commercial |
$0.01
|
| Rate for Payer: UHC Core |
$700.00
|
|
|
APPLICATION OF LOW COST SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA GREATER THAN OR EQUAL TO 100 SQ CM; FIRST 100 SQ CM WOUND SURFACE AREA, OR 1% OF BODY AREA OF INFANTS AND CHILDREN
|
Facility
|
OP
|
$5,632.99
|
|
|
Service Code
|
CPT C5273
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$960.64 |
| Max. Negotiated Rate |
$5,632.99 |
| Rate for Payer: Aetna Medicare |
$1,863.93
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,240.30
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,240.30
|
| Rate for Payer: BCBS Complete |
$1,008.67
|
| Rate for Payer: BCBS MAPPO |
$1,792.24
|
| Rate for Payer: BCBS Trust/PPO |
$1,401.99
|
| Rate for Payer: BCN Commercial |
$1,401.99
|
| Rate for Payer: BCN Medicare Advantage |
$1,792.24
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,792.24
|
| Rate for Payer: Mclaren Medicaid |
$960.64
|
| Rate for Payer: Mclaren Medicare |
$1,792.24
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,881.85
|
| Rate for Payer: Meridian Medicaid |
$1,008.67
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2,061.08
|
| Rate for Payer: Nomi Health Commercial |
$3,763.70
|
| Rate for Payer: PACE Medicare |
$1,702.63
|
| Rate for Payer: PACE SWMI |
$1,792.24
|
| Rate for Payer: PHP Medicare Advantage |
$1,792.24
|
| Rate for Payer: Priority Health Choice Medicaid |
$960.64
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$5,632.99
|
| Rate for Payer: Priority Health Medicare |
$1,792.24
|
| Rate for Payer: Priority Health Narrow Network |
$4,506.39
|
| Rate for Payer: Railroad Medicare Medicare |
$1,792.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$5,044.98
|
| Rate for Payer: UHC Core |
$2,014.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,792.24
|
| Rate for Payer: UHC Exchange |
$3,425.15
|
| Rate for Payer: UHC Medicare Advantage |
$1,792.24
|
| Rate for Payer: UHCCP Medicaid |
$960.64
|
| Rate for Payer: VA VA |
$1,792.24
|
|
|
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT)
|
Facility
|
OP
|
$700.00
|
|
|
Service Code
|
CPT 29515
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$47.82 |
| Max. Negotiated Rate |
$700.00 |
| Rate for Payer: Aetna Medicare |
$160.78
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$193.25
|
| Rate for Payer: Amish Plain Church Group Commercial |
$193.25
|
| Rate for Payer: BCBS Complete |
$87.01
|
| Rate for Payer: BCBS MAPPO |
$154.60
|
| Rate for Payer: BCBS Trust/PPO |
$110.39
|
| Rate for Payer: BCN Commercial |
$110.39
|
| Rate for Payer: BCN Medicare Advantage |
$154.60
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$154.60
|
| Rate for Payer: Mclaren Medicaid |
$82.87
|
| Rate for Payer: Mclaren Medicare |
$154.60
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$162.33
|
| Rate for Payer: Meridian Medicaid |
$87.01
|
| Rate for Payer: MI Amish Medical Board Commercial |
$177.79
|
| Rate for Payer: Nomi Health Commercial |
$324.66
|
| Rate for Payer: PACE Medicare |
$146.87
|
| Rate for Payer: PACE SWMI |
$154.60
|
| Rate for Payer: PHP Medicare Advantage |
$154.60
|
| Rate for Payer: Priority Health Choice Medicaid |
$82.87
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$485.91
|
| Rate for Payer: Priority Health Medicare |
$154.60
|
| Rate for Payer: Priority Health Narrow Network |
$388.73
|
| Rate for Payer: Railroad Medicare Medicare |
$154.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$52.60
|
| Rate for Payer: UHC Core |
$700.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$154.60
|
| Rate for Payer: UHC Exchange |
$47.82
|
| Rate for Payer: UHC Medicare Advantage |
$154.60
|
| Rate for Payer: UHCCP Medicaid |
$82.87
|
| Rate for Payer: VA VA |
$154.60
|
|
|
APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA GREATER THAN OR EQUAL TO 100 SQ CM; EACH ADDITIONAL 100 SQ CM WOUND SURFACE AREA, OR PART THEREOF, OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$700.00
|
|
|
Service Code
|
CPT 15278
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$53.85 |
| Max. Negotiated Rate |
$700.00 |
| Rate for Payer: BCBS Trust/PPO |
$308.28
|
| Rate for Payer: BCN Commercial |
$308.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$59.24
|
| Rate for Payer: UHC Core |
$700.00
|
| Rate for Payer: UHC Exchange |
$53.85
|
|
|
APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA GREATER THAN OR EQUAL TO 100 SQ CM; EACH ADDITIONAL 100 SQ CM WOUND SURFACE AREA, OR PART THEREOF, OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$700.00
|
|
|
Service Code
|
CPT 15278
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$53.85 |
| Max. Negotiated Rate |
$700.00 |
| Rate for Payer: BCBS Trust/PPO |
$308.28
|
| Rate for Payer: BCN Commercial |
$308.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$59.24
|
| Rate for Payer: UHC Core |
$700.00
|
| Rate for Payer: UHC Exchange |
$53.85
|
|
|
APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA GREATER THAN OR EQUAL TO 100 SQ CM; FIRST 100 SQ CM WOUND SURFACE AREA, OR 1% OF BODY AREA OF INFANTS AND CHILDREN
|
Facility
|
OP
|
$5,632.99
|
|
|
Service Code
|
CPT 15277
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$215.01 |
| Max. Negotiated Rate |
$5,632.99 |
| Rate for Payer: Aetna Medicare |
$1,863.93
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,240.30
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,240.30
|
| Rate for Payer: BCBS Complete |
$1,008.67
|
| Rate for Payer: BCBS MAPPO |
$1,792.24
|
| Rate for Payer: BCBS Trust/PPO |
$4,334.22
|
| Rate for Payer: BCN Commercial |
$4,334.22
|
| Rate for Payer: BCN Medicare Advantage |
$1,792.24
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,792.24
|
| Rate for Payer: Mclaren Medicaid |
$960.64
|
| Rate for Payer: Mclaren Medicare |
$1,792.24
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,881.85
|
| Rate for Payer: Meridian Medicaid |
$1,008.67
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2,061.08
|
| Rate for Payer: Nomi Health Commercial |
$3,763.70
|
| Rate for Payer: PACE Medicare |
$1,702.63
|
| Rate for Payer: PACE SWMI |
$1,792.24
|
| Rate for Payer: PHP Medicare Advantage |
$1,792.24
|
| Rate for Payer: Priority Health Choice Medicaid |
$960.64
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$5,632.99
|
| Rate for Payer: Priority Health Medicare |
$1,792.24
|
| Rate for Payer: Priority Health Narrow Network |
$4,506.39
|
| Rate for Payer: Railroad Medicare Medicare |
$1,792.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$236.51
|
| Rate for Payer: UHC Core |
$2,014.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,792.24
|
| Rate for Payer: UHC Exchange |
$215.01
|
| Rate for Payer: UHC Medicare Advantage |
$1,792.24
|
| Rate for Payer: UHCCP Medicaid |
$960.64
|
| Rate for Payer: VA VA |
$1,792.24
|
|
|
APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA GREATER THAN OR EQUAL TO 100 SQ CM; FIRST 100 SQ CM WOUND SURFACE AREA, OR 1% OF BODY AREA OF INFANTS AND CHILDREN
|
Facility
|
OP
|
$5,632.99
|
|
|
Service Code
|
CPT 15277
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$215.01 |
| Max. Negotiated Rate |
$5,632.99 |
| Rate for Payer: Aetna Medicare |
$1,863.93
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,240.30
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,240.30
|
| Rate for Payer: BCBS Complete |
$1,008.67
|
| Rate for Payer: BCBS MAPPO |
$1,792.24
|
| Rate for Payer: BCBS Trust/PPO |
$4,334.22
|
| Rate for Payer: BCN Commercial |
$4,334.22
|
| Rate for Payer: BCN Medicare Advantage |
$1,792.24
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,792.24
|
| Rate for Payer: Mclaren Medicaid |
$960.64
|
| Rate for Payer: Mclaren Medicare |
$1,792.24
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,881.85
|
| Rate for Payer: Meridian Medicaid |
$1,008.67
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2,061.08
|
| Rate for Payer: Nomi Health Commercial |
$3,763.70
|
| Rate for Payer: PACE Medicare |
$1,702.63
|
| Rate for Payer: PACE SWMI |
$1,792.24
|
| Rate for Payer: PHP Medicare Advantage |
$1,792.24
|
| Rate for Payer: Priority Health Choice Medicaid |
$960.64
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$5,632.99
|
| Rate for Payer: Priority Health Medicare |
$1,792.24
|
| Rate for Payer: Priority Health Narrow Network |
$4,506.39
|
| Rate for Payer: Railroad Medicare Medicare |
$1,792.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$236.51
|
| Rate for Payer: UHC Core |
$2,014.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,792.24
|
| Rate for Payer: UHC Exchange |
$215.01
|
| Rate for Payer: UHC Medicare Advantage |
$1,792.24
|
| Rate for Payer: UHCCP Medicaid |
$960.64
|
| Rate for Payer: VA VA |
$1,792.24
|
|
|
APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; EACH ADDITIONAL 25 SQ CM WOUND SURFACE AREA, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$700.00
|
|
|
Service Code
|
CPT 15276
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$24.13 |
| Max. Negotiated Rate |
$700.00 |
| Rate for Payer: BCBS Trust/PPO |
$125.10
|
| Rate for Payer: BCN Commercial |
$125.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$26.54
|
| Rate for Payer: UHC Core |
$700.00
|
| Rate for Payer: UHC Exchange |
$24.13
|
|
|
APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA
|
Facility
|
OP
|
$5,632.99
|
|
|
Service Code
|
CPT 15275
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$89.59 |
| Max. Negotiated Rate |
$5,632.99 |
| Rate for Payer: Aetna Medicare |
$1,863.93
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,240.30
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,240.30
|
| Rate for Payer: BCBS Complete |
$1,008.67
|
| Rate for Payer: BCBS MAPPO |
$1,792.24
|
| Rate for Payer: BCBS Trust/PPO |
$1,655.54
|
| Rate for Payer: BCN Commercial |
$1,655.54
|
| Rate for Payer: BCN Medicare Advantage |
$1,792.24
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,792.24
|
| Rate for Payer: Mclaren Medicaid |
$960.64
|
| Rate for Payer: Mclaren Medicare |
$1,792.24
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,881.85
|
| Rate for Payer: Meridian Medicaid |
$1,008.67
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2,061.08
|
| Rate for Payer: Nomi Health Commercial |
$3,763.70
|
| Rate for Payer: PACE Medicare |
$1,702.63
|
| Rate for Payer: PACE SWMI |
$1,792.24
|
| Rate for Payer: PHP Medicare Advantage |
$1,792.24
|
| Rate for Payer: Priority Health Choice Medicaid |
$960.64
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$5,632.99
|
| Rate for Payer: Priority Health Medicare |
$1,792.24
|
| Rate for Payer: Priority Health Narrow Network |
$4,506.39
|
| Rate for Payer: Railroad Medicare Medicare |
$1,792.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$98.55
|
| Rate for Payer: UHC Core |
$2,014.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,792.24
|
| Rate for Payer: UHC Exchange |
$89.59
|
| Rate for Payer: UHC Medicare Advantage |
$1,792.24
|
| Rate for Payer: UHCCP Medicaid |
$960.64
|
| Rate for Payer: VA VA |
$1,792.24
|
|
|
APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA
|
Facility
|
OP
|
$5,632.99
|
|
|
Service Code
|
CPT 15275
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$89.59 |
| Max. Negotiated Rate |
$5,632.99 |
| Rate for Payer: Aetna Medicare |
$1,863.93
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,240.30
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,240.30
|
| Rate for Payer: BCBS Complete |
$1,008.67
|
| Rate for Payer: BCBS MAPPO |
$1,792.24
|
| Rate for Payer: BCBS Trust/PPO |
$1,655.54
|
| Rate for Payer: BCN Commercial |
$1,655.54
|
| Rate for Payer: BCN Medicare Advantage |
$1,792.24
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,792.24
|
| Rate for Payer: Mclaren Medicaid |
$960.64
|
| Rate for Payer: Mclaren Medicare |
$1,792.24
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,881.85
|
| Rate for Payer: Meridian Medicaid |
$1,008.67
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2,061.08
|
| Rate for Payer: Nomi Health Commercial |
$3,763.70
|
| Rate for Payer: PACE Medicare |
$1,702.63
|
| Rate for Payer: PACE SWMI |
$1,792.24
|
| Rate for Payer: PHP Medicare Advantage |
$1,792.24
|
| Rate for Payer: Priority Health Choice Medicaid |
$960.64
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$5,632.99
|
| Rate for Payer: Priority Health Medicare |
$1,792.24
|
| Rate for Payer: Priority Health Narrow Network |
$4,506.39
|
| Rate for Payer: Railroad Medicare Medicare |
$1,792.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$98.55
|
| Rate for Payer: UHC Core |
$2,014.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,792.24
|
| Rate for Payer: UHC Exchange |
$89.59
|
| Rate for Payer: UHC Medicare Advantage |
$1,792.24
|
| Rate for Payer: UHCCP Medicaid |
$960.64
|
| Rate for Payer: VA VA |
$1,792.24
|
|
|
APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA GREATER THAN OR EQUAL TO 100 SQ CM; EACH ADDITIONAL 100 SQ CM WOUND SURFACE AREA, OR PART THEREOF, OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$700.00
|
|
|
Service Code
|
CPT 15274
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$43.17 |
| Max. Negotiated Rate |
$700.00 |
| Rate for Payer: BCBS Trust/PPO |
$257.75
|
| Rate for Payer: BCN Commercial |
$257.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$47.49
|
| Rate for Payer: UHC Core |
$700.00
|
| Rate for Payer: UHC Exchange |
$43.17
|
|
|
APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA GREATER THAN OR EQUAL TO 100 SQ CM; FIRST 100 SQ CM WOUND SURFACE AREA, OR 1% OF BODY AREA OF INFANTS AND CHILDREN
|
Facility
|
OP
|
$11,273.70
|
|
|
Service Code
|
CPT 15273
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$188.70 |
| Max. Negotiated Rate |
$11,273.70 |
| Rate for Payer: Aetna Medicare |
$3,730.43
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4,483.69
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4,483.69
|
| Rate for Payer: BCBS Complete |
$2,018.74
|
| Rate for Payer: BCBS MAPPO |
$3,586.95
|
| Rate for Payer: BCBS Trust/PPO |
$1,705.55
|
| Rate for Payer: BCN Commercial |
$1,705.55
|
| Rate for Payer: BCN Medicare Advantage |
$3,586.95
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,586.95
|
| Rate for Payer: Mclaren Medicaid |
$1,922.61
|
| Rate for Payer: Mclaren Medicare |
$3,586.95
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,766.30
|
| Rate for Payer: Meridian Medicaid |
$2,018.74
|
| Rate for Payer: MI Amish Medical Board Commercial |
$4,124.99
|
| Rate for Payer: Nomi Health Commercial |
$7,532.60
|
| Rate for Payer: PACE Medicare |
$3,407.60
|
| Rate for Payer: PACE SWMI |
$3,586.95
|
| Rate for Payer: PHP Medicare Advantage |
$3,586.95
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,922.61
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$11,273.70
|
| Rate for Payer: Priority Health Medicare |
$3,586.95
|
| Rate for Payer: Priority Health Narrow Network |
$9,018.96
|
| Rate for Payer: Railroad Medicare Medicare |
$3,586.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$207.57
|
| Rate for Payer: UHC Core |
$5,042.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,586.95
|
| Rate for Payer: UHC Exchange |
$188.70
|
| Rate for Payer: UHC Medicare Advantage |
$3,586.95
|
| Rate for Payer: UHCCP Medicaid |
$1,922.61
|
| Rate for Payer: VA VA |
$3,586.95
|
|
|
APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; EACH ADDITIONAL 25 SQ CM WOUND SURFACE AREA, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$700.00
|
|
|
Service Code
|
CPT 15272
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$16.31 |
| Max. Negotiated Rate |
$700.00 |
| Rate for Payer: BCBS Trust/PPO |
$97.29
|
| Rate for Payer: BCN Commercial |
$97.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$17.94
|
| Rate for Payer: UHC Core |
$700.00
|
| Rate for Payer: UHC Exchange |
$16.31
|
|
|
APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA
|
Facility
|
OP
|
$5,632.99
|
|
|
Service Code
|
CPT 15271
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$80.83 |
| Max. Negotiated Rate |
$5,632.99 |
| Rate for Payer: Aetna Medicare |
$1,863.93
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,240.30
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,240.30
|
| Rate for Payer: BCBS Complete |
$1,008.67
|
| Rate for Payer: BCBS MAPPO |
$1,792.24
|
| Rate for Payer: BCBS Trust/PPO |
$2,067.93
|
| Rate for Payer: BCN Commercial |
$2,067.93
|
| Rate for Payer: BCN Medicare Advantage |
$1,792.24
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,792.24
|
| Rate for Payer: Mclaren Medicaid |
$960.64
|
| Rate for Payer: Mclaren Medicare |
$1,792.24
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,881.85
|
| Rate for Payer: Meridian Medicaid |
$1,008.67
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2,061.08
|
| Rate for Payer: Nomi Health Commercial |
$3,763.70
|
| Rate for Payer: PACE Medicare |
$1,702.63
|
| Rate for Payer: PACE SWMI |
$1,792.24
|
| Rate for Payer: PHP Medicare Advantage |
$1,792.24
|
| Rate for Payer: Priority Health Choice Medicaid |
$960.64
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$5,632.99
|
| Rate for Payer: Priority Health Medicare |
$1,792.24
|
| Rate for Payer: Priority Health Narrow Network |
$4,506.39
|
| Rate for Payer: Railroad Medicare Medicare |
$1,792.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$88.91
|
| Rate for Payer: UHC Core |
$2,014.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,792.24
|
| Rate for Payer: UHC Exchange |
$80.83
|
| Rate for Payer: UHC Medicare Advantage |
$1,792.24
|
| Rate for Payer: UHCCP Medicaid |
$960.64
|
| Rate for Payer: VA VA |
$1,792.24
|
|
|
APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA
|
Facility
|
OP
|
$5,632.99
|
|
|
Service Code
|
CPT 15271
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$80.83 |
| Max. Negotiated Rate |
$5,632.99 |
| Rate for Payer: Aetna Medicare |
$1,863.93
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,240.30
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,240.30
|
| Rate for Payer: BCBS Complete |
$1,008.67
|
| Rate for Payer: BCBS MAPPO |
$1,792.24
|
| Rate for Payer: BCBS Trust/PPO |
$2,067.93
|
| Rate for Payer: BCN Commercial |
$2,067.93
|
| Rate for Payer: BCN Medicare Advantage |
$1,792.24
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,792.24
|
| Rate for Payer: Mclaren Medicaid |
$960.64
|
| Rate for Payer: Mclaren Medicare |
$1,792.24
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,881.85
|
| Rate for Payer: Meridian Medicaid |
$1,008.67
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2,061.08
|
| Rate for Payer: Nomi Health Commercial |
$3,763.70
|
| Rate for Payer: PACE Medicare |
$1,702.63
|
| Rate for Payer: PACE SWMI |
$1,792.24
|
| Rate for Payer: PHP Medicare Advantage |
$1,792.24
|
| Rate for Payer: Priority Health Choice Medicaid |
$960.64
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$5,632.99
|
| Rate for Payer: Priority Health Medicare |
$1,792.24
|
| Rate for Payer: Priority Health Narrow Network |
$4,506.39
|
| Rate for Payer: Railroad Medicare Medicare |
$1,792.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$88.91
|
| Rate for Payer: UHC Core |
$2,014.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,792.24
|
| Rate for Payer: UHC Exchange |
$80.83
|
| Rate for Payer: UHC Medicare Advantage |
$1,792.24
|
| Rate for Payer: UHCCP Medicaid |
$960.64
|
| Rate for Payer: VA VA |
$1,792.24
|
|
|
APRACLONIDINE 0.5 % EYE DROPS
|
Facility
|
OP
|
$146.86
|
|
|
Service Code
|
NDC 61314066505
|
| Hospital Charge Code |
9119
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$54.34 |
| Max. Negotiated Rate |
$132.17 |
| Rate for Payer: Aetna American Axle |
$95.46
|
| Rate for Payer: Aetna Commercial |
$124.83
|
| Rate for Payer: Aetna Medicare |
$73.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$95.46
|
| Rate for Payer: BCBS Complete |
$58.74
|
| Rate for Payer: Cash Price |
$117.49
|
| Rate for Payer: Cofinity Commercial |
$102.80
|
| Rate for Payer: Cofinity Commercial |
$126.30
|
| Rate for Payer: Cofinity Medicare Advantage |
$102.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$117.49
|
| Rate for Payer: Healthscope Commercial |
$132.17
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$102.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$110.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$124.83
|
| Rate for Payer: PHP Commercial |
$124.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$95.46
|
| Rate for Payer: Priority Health SBD |
$92.52
|
| Rate for Payer: UMR Bronson Commercial |
$54.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$110.14
|
|
|
APRACLONIDINE 0.5 % EYE DROPS
|
Facility
|
IP
|
$146.86
|
|
|
Service Code
|
NDC 61314066505
|
| Hospital Charge Code |
9119
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$64.62 |
| Max. Negotiated Rate |
$132.17 |
| Rate for Payer: Aetna American Axle |
$95.46
|
| Rate for Payer: Aetna Commercial |
$124.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$95.46
|
| Rate for Payer: Cash Price |
$117.49
|
| Rate for Payer: Cofinity Commercial |
$102.80
|
| Rate for Payer: Cofinity Commercial |
$126.30
|
| Rate for Payer: Cofinity Medicare Advantage |
$102.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$117.49
|
| Rate for Payer: Healthscope Commercial |
$132.17
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$102.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$110.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$124.83
|
| Rate for Payer: PHP Commercial |
$124.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$95.46
|
| Rate for Payer: Priority Health SBD |
$92.52
|
| Rate for Payer: UMR Bronson Commercial |
$64.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$110.14
|
|
|
APRACLONIDINE 1 % EYE DROPS IN A DROPPERETTE
|
Facility
|
IP
|
$2,289.89
|
|
|
Service Code
|
NDC 82667020001
|
| Hospital Charge Code |
9120
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,007.55 |
| Max. Negotiated Rate |
$2,060.90 |
| Rate for Payer: Aetna American Axle |
$1,488.43
|
| Rate for Payer: Aetna Commercial |
$1,946.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,488.43
|
| Rate for Payer: Cash Price |
$1,831.91
|
| Rate for Payer: Cofinity Commercial |
$1,602.92
|
| Rate for Payer: Cofinity Commercial |
$1,969.31
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,602.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,831.91
|
| Rate for Payer: Healthscope Commercial |
$2,060.90
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,602.92
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,717.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,946.41
|
| Rate for Payer: PHP Commercial |
$1,946.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,488.43
|
| Rate for Payer: Priority Health SBD |
$1,442.63
|
| Rate for Payer: UMR Bronson Commercial |
$1,007.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,717.42
|
|
|
APRACLONIDINE 1 % EYE DROPS IN A DROPPERETTE
|
Facility
|
OP
|
$95.42
|
|
|
Service Code
|
NDC 00065066010
|
| Hospital Charge Code |
9120
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$35.31 |
| Max. Negotiated Rate |
$85.88 |
| Rate for Payer: Aetna American Axle |
$62.02
|
| Rate for Payer: Aetna Commercial |
$81.11
|
| Rate for Payer: Aetna Medicare |
$47.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$62.02
|
| Rate for Payer: BCBS Complete |
$38.17
|
| Rate for Payer: Cash Price |
$76.34
|
| Rate for Payer: Cofinity Commercial |
$66.79
|
| Rate for Payer: Cofinity Commercial |
$82.06
|
| Rate for Payer: Cofinity Medicare Advantage |
$66.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$76.34
|
| Rate for Payer: Healthscope Commercial |
$85.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$66.79
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$71.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$81.11
|
| Rate for Payer: PHP Commercial |
$81.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$62.02
|
| Rate for Payer: Priority Health SBD |
$60.11
|
| Rate for Payer: UMR Bronson Commercial |
$35.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$71.56
|
|
|
APRACLONIDINE 1 % EYE DROPS IN A DROPPERETTE
|
Facility
|
OP
|
$2,289.89
|
|
|
Service Code
|
NDC 82667020001
|
| Hospital Charge Code |
9120
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$847.26 |
| Max. Negotiated Rate |
$2,060.90 |
| Rate for Payer: Aetna American Axle |
$1,488.43
|
| Rate for Payer: Aetna Commercial |
$1,946.41
|
| Rate for Payer: Aetna Medicare |
$1,144.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,488.43
|
| Rate for Payer: BCBS Complete |
$915.96
|
| Rate for Payer: Cash Price |
$1,831.91
|
| Rate for Payer: Cofinity Commercial |
$1,602.92
|
| Rate for Payer: Cofinity Commercial |
$1,969.31
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,602.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,831.91
|
| Rate for Payer: Healthscope Commercial |
$2,060.90
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,602.92
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,717.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,946.41
|
| Rate for Payer: PHP Commercial |
$1,946.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,488.43
|
| Rate for Payer: Priority Health SBD |
$1,442.63
|
| Rate for Payer: UMR Bronson Commercial |
$847.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,717.42
|
|
|
APRACLONIDINE 1 % EYE DROPS IN A DROPPERETTE
|
Facility
|
IP
|
$95.42
|
|
|
Service Code
|
NDC 00065066010
|
| Hospital Charge Code |
9120
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$41.98 |
| Max. Negotiated Rate |
$85.88 |
| Rate for Payer: Aetna American Axle |
$62.02
|
| Rate for Payer: Aetna Commercial |
$81.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$62.02
|
| Rate for Payer: Cash Price |
$76.34
|
| Rate for Payer: Cofinity Commercial |
$66.79
|
| Rate for Payer: Cofinity Commercial |
$82.06
|
| Rate for Payer: Cofinity Medicare Advantage |
$66.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$76.34
|
| Rate for Payer: Healthscope Commercial |
$85.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$66.79
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$71.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$81.11
|
| Rate for Payer: PHP Commercial |
$81.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$62.02
|
| Rate for Payer: Priority Health SBD |
$60.11
|
| Rate for Payer: UMR Bronson Commercial |
$41.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$71.56
|
|
|
APR-DRG 42.00: ABDOMINAL PAIN
|
Facility
|
IP
|
$3,933.43
|
|
|
Service Code
|
APR-DRG 2511
|
| Min. Negotiated Rate |
$3,746.12 |
| Max. Negotiated Rate |
$3,933.43 |
| Rate for Payer: BCBS Complete |
$3,933.43
|
| Rate for Payer: Mclaren Medicaid |
$3,746.12
|
| Rate for Payer: Meridian Medicaid |
$3,933.43
|
| Rate for Payer: Priority Health Choice Medicaid |
$3,746.12
|
| Rate for Payer: UHCCP Medicaid |
$3,746.12
|
|
