|
HC OSU OBSERVATION PER HOUR
|
Facility
|
OP
|
$134.33
|
|
|
Service Code
|
HCPCS G0378
|
| Hospital Charge Code |
76200009
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$49.70 |
| Max. Negotiated Rate |
$4,092.00 |
| Rate for Payer: Aetna American Axle |
$87.31
|
| Rate for Payer: Aetna Commercial |
$114.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$87.31
|
| Rate for Payer: BCBS Complete |
$53.73
|
| Rate for Payer: BCBS Trust/PPO |
$118.88
|
| Rate for Payer: Cash Price |
$107.46
|
| Rate for Payer: Cash Price |
$107.46
|
| Rate for Payer: Cash Price |
$107.46
|
| Rate for Payer: Cofinity Commercial |
$94.03
|
| Rate for Payer: Cofinity Commercial |
$115.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$107.46
|
| Rate for Payer: Healthscope Commercial |
$120.90
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$94.03
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$100.75
|
| Rate for Payer: Meridian Medicaid |
$1,000.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$114.18
|
| Rate for Payer: PHP Commercial |
$114.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$94.03
|
| Rate for Payer: Priority Health SBD |
$84.63
|
| Rate for Payer: UHC Core |
$4,092.00
|
| Rate for Payer: UMR Bronson Commercial |
$49.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$100.75
|
|
|
HC OT EVAL HIGH COMPLEXITY
|
Facility
|
IP
|
$273.77
|
|
|
Service Code
|
CPT 97167
|
| Hospital Charge Code |
43400009
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$120.46 |
| Max. Negotiated Rate |
$246.39 |
| Rate for Payer: Aetna American Axle |
$177.95
|
| Rate for Payer: Aetna Commercial |
$232.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$177.95
|
| Rate for Payer: Cash Price |
$219.02
|
| Rate for Payer: Cofinity Commercial |
$191.64
|
| Rate for Payer: Cofinity Commercial |
$235.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$219.02
|
| Rate for Payer: Healthscope Commercial |
$246.39
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$191.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$205.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$232.70
|
| Rate for Payer: PHP Commercial |
$232.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$191.64
|
| Rate for Payer: Priority Health SBD |
$172.48
|
| Rate for Payer: UMR Bronson Commercial |
$120.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$205.33
|
|
|
HC OT EVAL HIGH COMPLEXITY
|
Facility
|
OP
|
$273.77
|
|
|
Service Code
|
CPT 97167
|
| Hospital Charge Code |
43400009
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$60.80 |
| Max. Negotiated Rate |
$294.00 |
| Rate for Payer: Aetna American Axle |
$177.95
|
| Rate for Payer: Aetna Commercial |
$232.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$177.95
|
| Rate for Payer: BCBS Complete |
$109.51
|
| Rate for Payer: BCBS Trust/PPO |
$62.10
|
| Rate for Payer: Cash Price |
$219.02
|
| Rate for Payer: Cash Price |
$219.02
|
| Rate for Payer: Cash Price |
$219.02
|
| Rate for Payer: Cofinity Commercial |
$235.44
|
| Rate for Payer: Cofinity Commercial |
$191.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$219.02
|
| Rate for Payer: Healthscope Commercial |
$246.39
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$191.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$205.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$232.70
|
| Rate for Payer: PHP Commercial |
$232.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$191.64
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$76.00
|
| Rate for Payer: Priority Health Narrow Network |
$60.80
|
| Rate for Payer: Priority Health SBD |
$172.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$109.49
|
| Rate for Payer: UHC Core |
$294.00
|
| Rate for Payer: UHC Exchange |
$99.54
|
| Rate for Payer: UMR Bronson Commercial |
$101.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$205.33
|
|
|
HC OT EVAL LOW COMPLEXITY
|
Facility
|
IP
|
$223.99
|
|
|
Service Code
|
CPT 97165
|
| Hospital Charge Code |
43400007
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$98.56 |
| Max. Negotiated Rate |
$201.59 |
| Rate for Payer: Aetna American Axle |
$145.59
|
| Rate for Payer: Aetna Commercial |
$190.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$145.59
|
| Rate for Payer: Cash Price |
$179.19
|
| Rate for Payer: Cofinity Commercial |
$156.79
|
| Rate for Payer: Cofinity Commercial |
$192.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$179.19
|
| Rate for Payer: Healthscope Commercial |
$201.59
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$156.79
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$167.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$190.39
|
| Rate for Payer: PHP Commercial |
$190.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$156.79
|
| Rate for Payer: Priority Health SBD |
$141.11
|
| Rate for Payer: UMR Bronson Commercial |
$98.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$167.99
|
|
|
HC OT EVAL LOW COMPLEXITY
|
Facility
|
OP
|
$223.99
|
|
|
Service Code
|
CPT 97165
|
| Hospital Charge Code |
43400007
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$60.80 |
| Max. Negotiated Rate |
$294.00 |
| Rate for Payer: Aetna American Axle |
$145.59
|
| Rate for Payer: Aetna Commercial |
$190.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$145.59
|
| Rate for Payer: BCBS Complete |
$89.60
|
| Rate for Payer: BCBS Trust/PPO |
$62.34
|
| Rate for Payer: Cash Price |
$179.19
|
| Rate for Payer: Cash Price |
$179.19
|
| Rate for Payer: Cash Price |
$179.19
|
| Rate for Payer: Cofinity Commercial |
$156.79
|
| Rate for Payer: Cofinity Commercial |
$192.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$179.19
|
| Rate for Payer: Healthscope Commercial |
$201.59
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$156.79
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$167.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$190.39
|
| Rate for Payer: PHP Commercial |
$190.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$156.79
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$76.00
|
| Rate for Payer: Priority Health Narrow Network |
$60.80
|
| Rate for Payer: Priority Health SBD |
$141.11
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$109.49
|
| Rate for Payer: UHC Core |
$294.00
|
| Rate for Payer: UHC Exchange |
$99.54
|
| Rate for Payer: UMR Bronson Commercial |
$82.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$167.99
|
|
|
HC OT EVAL MODERATE COMPLEXITY
|
Facility
|
OP
|
$248.88
|
|
|
Service Code
|
CPT 97166
|
| Hospital Charge Code |
43400008
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$60.80 |
| Max. Negotiated Rate |
$294.00 |
| Rate for Payer: Aetna American Axle |
$161.77
|
| Rate for Payer: Aetna Commercial |
$211.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$161.77
|
| Rate for Payer: BCBS Complete |
$99.55
|
| Rate for Payer: BCBS Trust/PPO |
$62.10
|
| Rate for Payer: Cash Price |
$199.10
|
| Rate for Payer: Cash Price |
$199.10
|
| Rate for Payer: Cash Price |
$199.10
|
| Rate for Payer: Cofinity Commercial |
$214.04
|
| Rate for Payer: Cofinity Commercial |
$174.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$199.10
|
| Rate for Payer: Healthscope Commercial |
$223.99
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$174.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$186.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$211.55
|
| Rate for Payer: PHP Commercial |
$211.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$174.22
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$76.00
|
| Rate for Payer: Priority Health Narrow Network |
$60.80
|
| Rate for Payer: Priority Health SBD |
$156.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$109.49
|
| Rate for Payer: UHC Core |
$294.00
|
| Rate for Payer: UHC Exchange |
$99.54
|
| Rate for Payer: UMR Bronson Commercial |
$92.09
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$186.66
|
|
|
HC OT EVAL MODERATE COMPLEXITY
|
Facility
|
IP
|
$248.88
|
|
|
Service Code
|
CPT 97166
|
| Hospital Charge Code |
43400008
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$109.51 |
| Max. Negotiated Rate |
$223.99 |
| Rate for Payer: Aetna American Axle |
$161.77
|
| Rate for Payer: Aetna Commercial |
$211.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$161.77
|
| Rate for Payer: Cash Price |
$199.10
|
| Rate for Payer: Cofinity Commercial |
$174.22
|
| Rate for Payer: Cofinity Commercial |
$214.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$199.10
|
| Rate for Payer: Healthscope Commercial |
$223.99
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$174.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$186.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$211.55
|
| Rate for Payer: PHP Commercial |
$211.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$174.22
|
| Rate for Payer: Priority Health SBD |
$156.79
|
| Rate for Payer: UMR Bronson Commercial |
$109.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$186.66
|
|
|
HC OT RE-EVALUATION
|
Facility
|
OP
|
$118.00
|
|
|
Service Code
|
CPT 97168
|
| Hospital Charge Code |
43400010
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$30.40 |
| Max. Negotiated Rate |
$294.00 |
| Rate for Payer: Aetna American Axle |
$76.70
|
| Rate for Payer: Aetna Commercial |
$100.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$76.70
|
| Rate for Payer: BCBS Complete |
$47.20
|
| Rate for Payer: BCBS Trust/PPO |
$43.01
|
| Rate for Payer: Cash Price |
$94.40
|
| Rate for Payer: Cash Price |
$94.40
|
| Rate for Payer: Cash Price |
$94.40
|
| Rate for Payer: Cofinity Commercial |
$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: Kalamazoo County Sherrif's Dept Commercial |
$82.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$88.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$100.30
|
| Rate for Payer: PHP Commercial |
$100.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$82.60
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$38.00
|
| Rate for Payer: Priority Health Narrow Network |
$30.40
|
| Rate for Payer: Priority Health SBD |
$74.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$75.64
|
| Rate for Payer: UHC Core |
$294.00
|
| Rate for Payer: UHC Exchange |
$68.76
|
| Rate for Payer: UMR Bronson Commercial |
$43.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$88.50
|
|
|
HC OT RE-EVALUATION
|
Facility
|
IP
|
$118.00
|
|
|
Service Code
|
CPT 97168
|
| Hospital Charge Code |
43400010
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$51.92 |
| Max. Negotiated Rate |
$106.20 |
| Rate for Payer: Aetna American Axle |
$76.70
|
| 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 Commercial |
$101.48
|
| Rate for Payer: Cofinity Commercial |
$82.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$94.40
|
| Rate for Payer: Healthscope Commercial |
$106.20
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$82.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$88.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$100.30
|
| Rate for Payer: PHP Commercial |
$100.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$82.60
|
| Rate for Payer: Priority Health SBD |
$74.34
|
| Rate for Payer: UMR Bronson Commercial |
$51.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$88.50
|
|
|
HC OT Z GAUNTLET EA $100
|
Facility
|
IP
|
$100.00
|
|
|
Service Code
|
HCPCS A6549
|
| Hospital Charge Code |
98300074
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$44.00 |
| Max. Negotiated Rate |
$90.00 |
| Rate for Payer: Aetna American Axle |
$65.00
|
| Rate for Payer: Aetna Commercial |
$85.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$65.00
|
| Rate for Payer: Cash Price |
$80.00
|
| Rate for Payer: Cofinity Commercial |
$70.00
|
| Rate for Payer: Cofinity Commercial |
$86.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$80.00
|
| Rate for Payer: Healthscope Commercial |
$90.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$70.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$75.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$85.00
|
| Rate for Payer: PHP Commercial |
$85.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$70.00
|
| Rate for Payer: Priority Health SBD |
$63.00
|
| Rate for Payer: UMR Bronson Commercial |
$44.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$75.00
|
|
|
HC OT Z GAUNTLET EA $100
|
Facility
|
OP
|
$100.00
|
|
|
Service Code
|
HCPCS A6549
|
| Hospital Charge Code |
98300074
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$37.00 |
| Max. Negotiated Rate |
$416.51 |
| Rate for Payer: Aetna American Axle |
$65.00
|
| Rate for Payer: Aetna Commercial |
$85.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$65.00
|
| Rate for Payer: BCBS Complete |
$40.00
|
| Rate for Payer: BCBS Trust/PPO |
$416.51
|
| Rate for Payer: Cash Price |
$80.00
|
| Rate for Payer: Cash Price |
$80.00
|
| Rate for Payer: Cofinity Commercial |
$70.00
|
| Rate for Payer: Cofinity Commercial |
$86.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$80.00
|
| Rate for Payer: Healthscope Commercial |
$90.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$70.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$75.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$85.00
|
| Rate for Payer: PHP Commercial |
$85.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$70.00
|
| Rate for Payer: Priority Health SBD |
$63.00
|
| Rate for Payer: UMR Bronson Commercial |
$37.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$75.00
|
|
|
HC OT Z GAUNTLET EA $125
|
Facility
|
IP
|
$125.00
|
|
|
Service Code
|
HCPCS A6549
|
| Hospital Charge Code |
98300075
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$55.00 |
| Max. Negotiated Rate |
$112.50 |
| Rate for Payer: Aetna American Axle |
$81.25
|
| Rate for Payer: Aetna Commercial |
$106.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$81.25
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cofinity Commercial |
$107.50
|
| Rate for Payer: Cofinity Commercial |
$87.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$100.00
|
| Rate for Payer: Healthscope Commercial |
$112.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$87.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$93.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$106.25
|
| Rate for Payer: PHP Commercial |
$106.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$87.50
|
| Rate for Payer: Priority Health SBD |
$78.75
|
| Rate for Payer: UMR Bronson Commercial |
$55.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$93.75
|
|
|
HC OT Z GAUNTLET EA $125
|
Facility
|
OP
|
$125.00
|
|
|
Service Code
|
HCPCS A6549
|
| Hospital Charge Code |
98300075
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$46.25 |
| Max. Negotiated Rate |
$416.51 |
| Rate for Payer: Aetna American Axle |
$81.25
|
| Rate for Payer: Aetna Commercial |
$106.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$81.25
|
| Rate for Payer: BCBS Complete |
$50.00
|
| Rate for Payer: BCBS Trust/PPO |
$416.51
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cofinity Commercial |
$107.50
|
| Rate for Payer: Cofinity Commercial |
$87.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$100.00
|
| Rate for Payer: Healthscope Commercial |
$112.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$87.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$93.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$106.25
|
| Rate for Payer: PHP Commercial |
$106.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$87.50
|
| Rate for Payer: Priority Health SBD |
$78.75
|
| Rate for Payer: UMR Bronson Commercial |
$46.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$93.75
|
|
|
HC OT Z GAUNTLET EA $150
|
Facility
|
IP
|
$150.00
|
|
|
Service Code
|
HCPCS A6549
|
| Hospital Charge Code |
98300076
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$66.00 |
| Max. Negotiated Rate |
$135.00 |
| Rate for Payer: Aetna American Axle |
$97.50
|
| 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 Commercial |
$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: Kalamazoo County Sherrif's Dept Commercial |
$105.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$112.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$127.50
|
| Rate for Payer: PHP Commercial |
$127.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$105.00
|
| Rate for Payer: Priority Health SBD |
$94.50
|
| Rate for Payer: UMR Bronson Commercial |
$66.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$112.50
|
|
|
HC OT Z GAUNTLET EA $150
|
Facility
|
OP
|
$150.00
|
|
|
Service Code
|
HCPCS A6549
|
| Hospital Charge Code |
98300076
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$55.50 |
| Max. Negotiated Rate |
$416.51 |
| Rate for Payer: Aetna American Axle |
$97.50
|
| Rate for Payer: Aetna Commercial |
$127.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$97.50
|
| Rate for Payer: BCBS Complete |
$60.00
|
| Rate for Payer: BCBS Trust/PPO |
$416.51
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Cofinity Commercial |
$129.00
|
| Rate for Payer: Cofinity Commercial |
$105.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$120.00
|
| Rate for Payer: Healthscope Commercial |
$135.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$105.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$112.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$127.50
|
| Rate for Payer: PHP Commercial |
$127.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$105.00
|
| Rate for Payer: Priority Health SBD |
$94.50
|
| Rate for Payer: UMR Bronson Commercial |
$55.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$112.50
|
|
|
HC OT Z GAUNTLET EA $175
|
Facility
|
OP
|
$175.00
|
|
|
Service Code
|
HCPCS A6549
|
| Hospital Charge Code |
98300077
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$64.75 |
| Max. Negotiated Rate |
$416.51 |
| Rate for Payer: Aetna American Axle |
$113.75
|
| Rate for Payer: Aetna Commercial |
$148.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$113.75
|
| Rate for Payer: BCBS Complete |
$70.00
|
| Rate for Payer: BCBS Trust/PPO |
$416.51
|
| Rate for Payer: Cash Price |
$140.00
|
| Rate for Payer: Cash Price |
$140.00
|
| Rate for Payer: Cofinity Commercial |
$122.50
|
| Rate for Payer: Cofinity Commercial |
$150.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$140.00
|
| Rate for Payer: Healthscope Commercial |
$157.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$122.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$131.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$148.75
|
| Rate for Payer: PHP Commercial |
$148.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$122.50
|
| Rate for Payer: Priority Health SBD |
$110.25
|
| Rate for Payer: UMR Bronson Commercial |
$64.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$131.25
|
|
|
HC OT Z GAUNTLET EA $175
|
Facility
|
IP
|
$175.00
|
|
|
Service Code
|
HCPCS A6549
|
| Hospital Charge Code |
98300077
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$77.00 |
| Max. Negotiated Rate |
$157.50 |
| Rate for Payer: Aetna American Axle |
$113.75
|
| Rate for Payer: Aetna Commercial |
$148.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$113.75
|
| Rate for Payer: Cash Price |
$140.00
|
| Rate for Payer: Cofinity Commercial |
$122.50
|
| Rate for Payer: Cofinity Commercial |
$150.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$140.00
|
| Rate for Payer: Healthscope Commercial |
$157.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$122.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$131.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$148.75
|
| Rate for Payer: PHP Commercial |
$148.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$122.50
|
| Rate for Payer: Priority Health SBD |
$110.25
|
| Rate for Payer: UMR Bronson Commercial |
$77.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$131.25
|
|
|
HC OT Z GAUNTLET EA $20
|
Facility
|
IP
|
$20.00
|
|
|
Service Code
|
HCPCS A6549
|
| Hospital Charge Code |
98300078
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$8.80 |
| Max. Negotiated Rate |
$18.00 |
| Rate for Payer: Aetna American Axle |
$13.00
|
| Rate for Payer: Aetna Commercial |
$17.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.00
|
| Rate for Payer: Cash Price |
$16.00
|
| Rate for Payer: Cofinity Commercial |
$14.00
|
| Rate for Payer: Cofinity Commercial |
$17.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.00
|
| Rate for Payer: Healthscope Commercial |
$18.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$17.00
|
| Rate for Payer: PHP Commercial |
$17.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.00
|
| Rate for Payer: Priority Health SBD |
$12.60
|
| Rate for Payer: UMR Bronson Commercial |
$8.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.00
|
|
|
HC OT Z GAUNTLET EA $20
|
Facility
|
OP
|
$20.00
|
|
|
Service Code
|
HCPCS A6549
|
| Hospital Charge Code |
98300078
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$7.40 |
| Max. Negotiated Rate |
$416.51 |
| Rate for Payer: Aetna American Axle |
$13.00
|
| Rate for Payer: Aetna Commercial |
$17.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.00
|
| Rate for Payer: BCBS Complete |
$8.00
|
| Rate for Payer: BCBS Trust/PPO |
$416.51
|
| Rate for Payer: Cash Price |
$16.00
|
| Rate for Payer: Cash Price |
$16.00
|
| Rate for Payer: Cofinity Commercial |
$17.20
|
| Rate for Payer: Cofinity Commercial |
$14.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.00
|
| Rate for Payer: Healthscope Commercial |
$18.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$17.00
|
| Rate for Payer: PHP Commercial |
$17.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.00
|
| Rate for Payer: Priority Health SBD |
$12.60
|
| Rate for Payer: UMR Bronson Commercial |
$7.40
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.00
|
|
|
HC OT Z GAUNTLET EA $200
|
Facility
|
OP
|
$200.00
|
|
|
Service Code
|
HCPCS A6549
|
| Hospital Charge Code |
98300079
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$74.00 |
| Max. Negotiated Rate |
$416.51 |
| Rate for Payer: Aetna American Axle |
$130.00
|
| Rate for Payer: Aetna Commercial |
$170.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$130.00
|
| Rate for Payer: BCBS Complete |
$80.00
|
| Rate for Payer: BCBS Trust/PPO |
$416.51
|
| Rate for Payer: Cash Price |
$160.00
|
| Rate for Payer: Cash Price |
$160.00
|
| Rate for Payer: Cofinity Commercial |
$140.00
|
| Rate for Payer: Cofinity Commercial |
$172.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$160.00
|
| Rate for Payer: Healthscope Commercial |
$180.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$140.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$150.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$170.00
|
| Rate for Payer: PHP Commercial |
$170.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$140.00
|
| Rate for Payer: Priority Health SBD |
$126.00
|
| Rate for Payer: UMR Bronson Commercial |
$74.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$150.00
|
|
|
HC OT Z GAUNTLET EA $200
|
Facility
|
IP
|
$200.00
|
|
|
Service Code
|
HCPCS A6549
|
| Hospital Charge Code |
98300079
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$88.00 |
| Max. Negotiated Rate |
$180.00 |
| Rate for Payer: Aetna American Axle |
$130.00
|
| Rate for Payer: Aetna Commercial |
$170.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$130.00
|
| Rate for Payer: Cash Price |
$160.00
|
| Rate for Payer: Cofinity Commercial |
$140.00
|
| Rate for Payer: Cofinity Commercial |
$172.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$160.00
|
| Rate for Payer: Healthscope Commercial |
$180.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$140.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$150.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$170.00
|
| Rate for Payer: PHP Commercial |
$170.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$140.00
|
| Rate for Payer: Priority Health SBD |
$126.00
|
| Rate for Payer: UMR Bronson Commercial |
$88.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$150.00
|
|
|
HC OT Z GAUNTLET EA $225
|
Facility
|
IP
|
$225.00
|
|
|
Service Code
|
HCPCS A6549
|
| Hospital Charge Code |
98300080
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$99.00 |
| Max. Negotiated Rate |
$202.50 |
| Rate for Payer: Aetna American Axle |
$146.25
|
| Rate for Payer: Aetna Commercial |
$191.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$146.25
|
| Rate for Payer: Cash Price |
$180.00
|
| Rate for Payer: Cofinity Commercial |
$157.50
|
| Rate for Payer: Cofinity Commercial |
$193.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$180.00
|
| Rate for Payer: Healthscope Commercial |
$202.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$157.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$168.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$191.25
|
| Rate for Payer: PHP Commercial |
$191.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$157.50
|
| Rate for Payer: Priority Health SBD |
$141.75
|
| Rate for Payer: UMR Bronson Commercial |
$99.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$168.75
|
|
|
HC OT Z GAUNTLET EA $225
|
Facility
|
OP
|
$225.00
|
|
|
Service Code
|
HCPCS A6549
|
| Hospital Charge Code |
98300080
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$83.25 |
| Max. Negotiated Rate |
$416.51 |
| Rate for Payer: Aetna American Axle |
$146.25
|
| Rate for Payer: Aetna Commercial |
$191.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$146.25
|
| Rate for Payer: BCBS Complete |
$90.00
|
| Rate for Payer: BCBS Trust/PPO |
$416.51
|
| Rate for Payer: Cash Price |
$180.00
|
| Rate for Payer: Cash Price |
$180.00
|
| Rate for Payer: Cofinity Commercial |
$193.50
|
| Rate for Payer: Cofinity Commercial |
$157.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$180.00
|
| Rate for Payer: Healthscope Commercial |
$202.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$157.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$168.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$191.25
|
| Rate for Payer: PHP Commercial |
$191.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$157.50
|
| Rate for Payer: Priority Health SBD |
$141.75
|
| Rate for Payer: UMR Bronson Commercial |
$83.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$168.75
|
|
|
HC OT Z GAUNTLET EA $250
|
Facility
|
IP
|
$250.00
|
|
|
Service Code
|
HCPCS A6549
|
| Hospital Charge Code |
98300081
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$110.00 |
| Max. Negotiated Rate |
$225.00 |
| Rate for Payer: Aetna American Axle |
$162.50
|
| Rate for Payer: Aetna Commercial |
$212.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$162.50
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cofinity Commercial |
$175.00
|
| Rate for Payer: Cofinity Commercial |
$215.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$200.00
|
| Rate for Payer: Healthscope Commercial |
$225.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$175.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$187.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$212.50
|
| Rate for Payer: PHP Commercial |
$212.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$175.00
|
| Rate for Payer: Priority Health SBD |
$157.50
|
| Rate for Payer: UMR Bronson Commercial |
$110.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$187.50
|
|
|
HC OT Z GAUNTLET EA $250
|
Facility
|
OP
|
$250.00
|
|
|
Service Code
|
HCPCS A6549
|
| Hospital Charge Code |
98300081
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$92.50 |
| Max. Negotiated Rate |
$416.51 |
| Rate for Payer: Aetna American Axle |
$162.50
|
| Rate for Payer: Aetna Commercial |
$212.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$162.50
|
| Rate for Payer: BCBS Complete |
$100.00
|
| Rate for Payer: BCBS Trust/PPO |
$416.51
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cofinity Commercial |
$175.00
|
| Rate for Payer: Cofinity Commercial |
$215.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$200.00
|
| Rate for Payer: Healthscope Commercial |
$225.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$175.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$187.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$212.50
|
| Rate for Payer: PHP Commercial |
$212.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$175.00
|
| Rate for Payer: Priority Health SBD |
$157.50
|
| Rate for Payer: UMR Bronson Commercial |
$92.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$187.50
|
|
