|
INHALATIONAL SPACING DEVICE
|
Facility
|
IP
|
$29.35
|
|
|
Service Code
|
NDC 8373-077478
|
| Hospital Charge Code |
113188
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.91 |
| Max. Negotiated Rate |
$26.42 |
| Rate for Payer: Aetna American Axle |
$19.08
|
| Rate for Payer: Aetna Commercial |
$24.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$19.08
|
| Rate for Payer: Cash Price |
$23.48
|
| Rate for Payer: Cofinity Commercial |
$20.54
|
| Rate for Payer: Cofinity Commercial |
$25.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.48
|
| Rate for Payer: Healthscope Commercial |
$26.42
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$20.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$22.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$24.95
|
| Rate for Payer: PHP Commercial |
$24.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.54
|
| Rate for Payer: Priority Health SBD |
$18.49
|
| Rate for Payer: UMR Bronson Commercial |
$12.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$22.01
|
|
|
INHALATIONAL SPACING DEVICE
|
Facility
|
IP
|
$39.08
|
|
|
Service Code
|
NDC 8373747800
|
| Hospital Charge Code |
113188
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.20 |
| Max. Negotiated Rate |
$35.17 |
| Rate for Payer: Aetna American Axle |
$25.40
|
| Rate for Payer: Aetna Commercial |
$33.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.40
|
| Rate for Payer: Cash Price |
$31.26
|
| Rate for Payer: Cofinity Commercial |
$27.36
|
| Rate for Payer: Cofinity Commercial |
$33.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$31.26
|
| Rate for Payer: Healthscope Commercial |
$35.17
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$27.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$29.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$33.22
|
| Rate for Payer: PHP Commercial |
$33.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$27.36
|
| Rate for Payer: Priority Health SBD |
$24.62
|
| Rate for Payer: UMR Bronson Commercial |
$17.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$29.31
|
|
|
INJECTION, ANESTHETIC AGENT; STELLATE GANGLION (CERVICAL SYMPATHETIC)
|
Facility
|
OP
|
$2,550.52
|
|
|
Service Code
|
CPT 64510
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$75.31 |
| Max. Negotiated Rate |
$2,550.52 |
| Rate for Payer: Aetna Medicare |
$842.60
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1,012.74
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1,012.74
|
| Rate for Payer: BCBS Complete |
$465.37
|
| Rate for Payer: BCBS MAPPO |
$810.19
|
| Rate for Payer: BCBS Trust/PPO |
$626.61
|
| Rate for Payer: BCN Medicare Advantage |
$810.19
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$810.19
|
| Rate for Payer: Mclaren Medicaid |
$443.17
|
| Rate for Payer: Mclaren Medicare |
$810.19
|
| Rate for Payer: Meridian Medicaid |
$465.37
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$850.70
|
| Rate for Payer: MI Amish Medical Board Commercial |
$931.72
|
| Rate for Payer: PACE Medicare |
$769.68
|
| Rate for Payer: PACE SWMI |
$810.19
|
| Rate for Payer: PHP Medicare Advantage |
$810.19
|
| Rate for Payer: Priority Health Choice Medicaid |
$443.17
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2,550.52
|
| Rate for Payer: Priority Health Medicare |
$810.19
|
| Rate for Payer: Priority Health Narrow Network |
$2,040.42
|
| Rate for Payer: Railroad Medicare Medicare |
$810.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$82.84
|
| Rate for Payer: UHC Core |
$981.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$810.19
|
| Rate for Payer: UHC Exchange |
$75.31
|
| Rate for Payer: UHC Medicare Advantage |
$834.50
|
| Rate for Payer: VA VA |
$810.19
|
|
|
INJECTION, INTRALESIONAL; UP TO AND INCLUDING 7 LESIONS
|
Facility
|
OP
|
$700.00
|
|
|
Service Code
|
CPT 11900
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$29.14 |
| Max. Negotiated Rate |
$700.00 |
| Rate for Payer: Aetna Medicare |
$185.07
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$222.44
|
| Rate for Payer: Amish Plain Church Group Commercial |
$222.44
|
| Rate for Payer: BCBS Complete |
$102.21
|
| Rate for Payer: BCBS MAPPO |
$177.95
|
| Rate for Payer: BCBS Trust/PPO |
$213.12
|
| Rate for Payer: BCN Medicare Advantage |
$177.95
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$177.95
|
| Rate for Payer: Mclaren Medicaid |
$97.34
|
| Rate for Payer: Mclaren Medicare |
$177.95
|
| Rate for Payer: Meridian Medicaid |
$102.21
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$186.85
|
| Rate for Payer: MI Amish Medical Board Commercial |
$204.64
|
| Rate for Payer: PACE Medicare |
$169.05
|
| Rate for Payer: PACE SWMI |
$177.95
|
| Rate for Payer: PHP Medicare Advantage |
$177.95
|
| Rate for Payer: Priority Health Choice Medicaid |
$97.34
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$560.20
|
| Rate for Payer: Priority Health Medicare |
$177.95
|
| Rate for Payer: Priority Health Narrow Network |
$448.16
|
| Rate for Payer: Railroad Medicare Medicare |
$177.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$32.05
|
| Rate for Payer: UHC Core |
$700.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$177.95
|
| Rate for Payer: UHC Exchange |
$29.14
|
| Rate for Payer: UHC Medicare Advantage |
$183.29
|
| Rate for Payer: VA VA |
$177.95
|
|
|
INJECTION PROCEDURE FOR ELBOW ARTHROGRAPHY
|
Facility
|
OP
|
$700.00
|
|
|
Service Code
|
CPT 24220
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$64.18 |
| Max. Negotiated Rate |
$700.00 |
| Rate for Payer: BCBS Trust/PPO |
$410.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$70.60
|
| Rate for Payer: UHC Core |
$700.00
|
| Rate for Payer: UHC Exchange |
$64.18
|
|
|
INJECTION PROCEDURE FOR EXTREMITY VENOGRAPHY (INCLUDING INTRODUCTION OF NEEDLE OR INTRACATHETER)
|
Facility
|
OP
|
$1,814.54
|
|
|
Service Code
|
CPT 36005
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$45.51 |
| Max. Negotiated Rate |
$1,814.54 |
| Rate for Payer: BCBS Trust/PPO |
$1,814.54
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$50.06
|
| Rate for Payer: UHC Core |
$700.00
|
| Rate for Payer: UHC Exchange |
$45.51
|
|
|
INJECTION PROCEDURE FOR HIP ARTHROGRAPHY; WITH ANESTHESIA
|
Facility
|
OP
|
$1,495.57
|
|
|
Service Code
|
CPT 27095
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$79.57 |
| Max. Negotiated Rate |
$1,495.57 |
| Rate for Payer: BCBS Trust/PPO |
$1,495.57
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$87.53
|
| Rate for Payer: UHC Core |
$700.00
|
| Rate for Payer: UHC Exchange |
$79.57
|
|
|
INJECTION PROCEDURE FOR SACROILIAC JOINT, ANESTHETIC/STEROID, WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT) INCLUDING ARTHROGRAPHY WHEN PERFORMED
|
Facility
|
OP
|
$733.81
|
|
|
Service Code
|
CPT 27096
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$80.88 |
| Max. Negotiated Rate |
$733.81 |
| Rate for Payer: BCBS Trust/PPO |
$733.81
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$323.52
|
| Rate for Payer: Priority Health Narrow Network |
$258.82
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$88.97
|
| Rate for Payer: UHC Core |
$700.00
|
| Rate for Payer: UHC Exchange |
$80.88
|
|
|
INJECTION PROCEDURE FOR SACROILIAC JOINT; PROVISION OF ANESTHETIC, STEROID AND/OR OTHER THERAPEUTIC AGENT, WITH OR WITHOUT ARTHROGRAPHY
|
Facility
|
OP
|
$1,935.09
|
|
|
Service Code
|
CPT G0260
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$336.24 |
| Max. Negotiated Rate |
$1,935.09 |
| Rate for Payer: Aetna Medicare |
$639.29
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$768.38
|
| Rate for Payer: Amish Plain Church Group Commercial |
$768.38
|
| Rate for Payer: BCBS Complete |
$353.08
|
| Rate for Payer: BCBS MAPPO |
$614.70
|
| Rate for Payer: BCBS Trust/PPO |
$568.60
|
| Rate for Payer: BCN Medicare Advantage |
$614.70
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$614.70
|
| Rate for Payer: Mclaren Medicaid |
$336.24
|
| Rate for Payer: Mclaren Medicare |
$614.70
|
| Rate for Payer: Meridian Medicaid |
$353.08
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$645.44
|
| Rate for Payer: MI Amish Medical Board Commercial |
$706.90
|
| Rate for Payer: PACE Medicare |
$583.96
|
| Rate for Payer: PACE SWMI |
$614.70
|
| Rate for Payer: PHP Medicare Advantage |
$614.70
|
| Rate for Payer: Priority Health Choice Medicaid |
$336.24
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,935.09
|
| Rate for Payer: Priority Health Medicare |
$614.70
|
| Rate for Payer: Priority Health Narrow Network |
$1,548.07
|
| Rate for Payer: Railroad Medicare Medicare |
$614.70
|
| Rate for Payer: UHC Core |
$981.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$614.70
|
| Rate for Payer: UHC Medicare Advantage |
$633.14
|
| Rate for Payer: VA VA |
$614.70
|
|
|
INJECTION PROCEDURE FOR SACROILIAC JOINT; PROVISION OF ANESTHETIC, STEROID AND/OR OTHER THERAPEUTIC AGENT, WITH OR WITHOUT ARTHROGRAPHY
|
Facility
|
OP
|
$1,935.09
|
|
|
Service Code
|
CPT G0260
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$336.24 |
| Max. Negotiated Rate |
$1,935.09 |
| Rate for Payer: Aetna Medicare |
$639.29
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$768.38
|
| Rate for Payer: Amish Plain Church Group Commercial |
$768.38
|
| Rate for Payer: BCBS Complete |
$353.08
|
| Rate for Payer: BCBS MAPPO |
$614.70
|
| Rate for Payer: BCBS Trust/PPO |
$568.60
|
| Rate for Payer: BCN Medicare Advantage |
$614.70
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$614.70
|
| Rate for Payer: Mclaren Medicaid |
$336.24
|
| Rate for Payer: Mclaren Medicare |
$614.70
|
| Rate for Payer: Meridian Medicaid |
$353.08
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$645.44
|
| Rate for Payer: MI Amish Medical Board Commercial |
$706.90
|
| Rate for Payer: PACE Medicare |
$583.96
|
| Rate for Payer: PACE SWMI |
$614.70
|
| Rate for Payer: PHP Medicare Advantage |
$614.70
|
| Rate for Payer: Priority Health Choice Medicaid |
$336.24
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,935.09
|
| Rate for Payer: Priority Health Medicare |
$614.70
|
| Rate for Payer: Priority Health Narrow Network |
$1,548.07
|
| Rate for Payer: Railroad Medicare Medicare |
$614.70
|
| Rate for Payer: UHC Core |
$981.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$614.70
|
| Rate for Payer: UHC Medicare Advantage |
$633.14
|
| Rate for Payer: VA VA |
$614.70
|
|
|
INJECTION PROCEDURE; RADIOACTIVE TRACER FOR IDENTIFICATION OF SENTINEL NODE
|
Facility
|
OP
|
$1,154.12
|
|
|
Service Code
|
CPT 38792
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$31.11 |
| Max. Negotiated Rate |
$1,154.12 |
| Rate for Payer: Aetna Medicare |
$381.27
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$458.26
|
| Rate for Payer: Amish Plain Church Group Commercial |
$458.26
|
| Rate for Payer: BCBS Complete |
$210.58
|
| Rate for Payer: BCBS MAPPO |
$366.61
|
| Rate for Payer: BCBS Trust/PPO |
$139.79
|
| Rate for Payer: BCN Medicare Advantage |
$366.61
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$366.61
|
| Rate for Payer: Mclaren Medicaid |
$200.54
|
| Rate for Payer: Mclaren Medicare |
$366.61
|
| Rate for Payer: Meridian Medicaid |
$210.58
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$384.94
|
| Rate for Payer: MI Amish Medical Board Commercial |
$421.60
|
| Rate for Payer: PACE Medicare |
$348.28
|
| Rate for Payer: PACE SWMI |
$366.61
|
| Rate for Payer: PHP Medicare Advantage |
$366.61
|
| Rate for Payer: Priority Health Choice Medicaid |
$200.54
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,154.12
|
| Rate for Payer: Priority Health Medicare |
$366.61
|
| Rate for Payer: Priority Health Narrow Network |
$923.30
|
| Rate for Payer: Railroad Medicare Medicare |
$366.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$34.22
|
| Rate for Payer: UHC Core |
$700.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$366.61
|
| Rate for Payer: UHC Exchange |
$31.11
|
| Rate for Payer: UHC Medicare Advantage |
$377.61
|
| Rate for Payer: VA VA |
$366.61
|
|
|
INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; FEMORAL NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED
|
Facility
|
OP
|
$1,935.09
|
|
|
Service Code
|
CPT 64447
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$61.23 |
| Max. Negotiated Rate |
$1,935.09 |
| Rate for Payer: Aetna Medicare |
$639.29
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$768.38
|
| Rate for Payer: Amish Plain Church Group Commercial |
$768.38
|
| Rate for Payer: BCBS Complete |
$353.08
|
| Rate for Payer: BCBS MAPPO |
$614.70
|
| Rate for Payer: BCBS Trust/PPO |
$79.67
|
| Rate for Payer: BCN Medicare Advantage |
$614.70
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$614.70
|
| Rate for Payer: Mclaren Medicaid |
$336.24
|
| Rate for Payer: Mclaren Medicare |
$614.70
|
| Rate for Payer: Meridian Medicaid |
$353.08
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$645.44
|
| Rate for Payer: MI Amish Medical Board Commercial |
$706.90
|
| Rate for Payer: PACE Medicare |
$583.96
|
| Rate for Payer: PACE SWMI |
$614.70
|
| Rate for Payer: PHP Medicare Advantage |
$614.70
|
| Rate for Payer: Priority Health Choice Medicaid |
$336.24
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,935.09
|
| Rate for Payer: Priority Health Medicare |
$614.70
|
| Rate for Payer: Priority Health Narrow Network |
$1,548.07
|
| Rate for Payer: Railroad Medicare Medicare |
$614.70
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$67.35
|
| Rate for Payer: UHC Core |
$981.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$614.70
|
| Rate for Payer: UHC Exchange |
$61.23
|
| Rate for Payer: UHC Medicare Advantage |
$633.14
|
| Rate for Payer: VA VA |
$614.70
|
|
|
INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH
|
Facility
|
OP
|
$1,935.09
|
|
|
Service Code
|
CPT 64450
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$40.93 |
| Max. Negotiated Rate |
$1,935.09 |
| Rate for Payer: Aetna Medicare |
$639.29
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$768.38
|
| Rate for Payer: Amish Plain Church Group Commercial |
$768.38
|
| Rate for Payer: BCBS Complete |
$353.08
|
| Rate for Payer: BCBS MAPPO |
$614.70
|
| Rate for Payer: BCBS Trust/PPO |
$689.06
|
| Rate for Payer: BCN Medicare Advantage |
$614.70
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$614.70
|
| Rate for Payer: Mclaren Medicaid |
$336.24
|
| Rate for Payer: Mclaren Medicare |
$614.70
|
| Rate for Payer: Meridian Medicaid |
$353.08
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$645.44
|
| Rate for Payer: MI Amish Medical Board Commercial |
$706.90
|
| Rate for Payer: PACE Medicare |
$583.96
|
| Rate for Payer: PACE SWMI |
$614.70
|
| Rate for Payer: PHP Medicare Advantage |
$614.70
|
| Rate for Payer: Priority Health Choice Medicaid |
$336.24
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,935.09
|
| Rate for Payer: Priority Health Medicare |
$614.70
|
| Rate for Payer: Priority Health Narrow Network |
$1,548.07
|
| Rate for Payer: Railroad Medicare Medicare |
$614.70
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$45.02
|
| Rate for Payer: UHC Core |
$981.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$614.70
|
| Rate for Payer: UHC Exchange |
$40.93
|
| Rate for Payer: UHC Medicare Advantage |
$633.14
|
| Rate for Payer: VA VA |
$614.70
|
|
|
INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; PUDENDAL NERVE
|
Facility
|
OP
|
$2,550.52
|
|
|
Service Code
|
CPT 64430
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$53.37 |
| Max. Negotiated Rate |
$2,550.52 |
| Rate for Payer: Aetna Medicare |
$842.60
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1,012.74
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1,012.74
|
| Rate for Payer: BCBS Complete |
$465.37
|
| Rate for Payer: BCBS MAPPO |
$810.19
|
| Rate for Payer: BCBS Trust/PPO |
$841.86
|
| Rate for Payer: BCN Medicare Advantage |
$810.19
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$810.19
|
| Rate for Payer: Mclaren Medicaid |
$443.17
|
| Rate for Payer: Mclaren Medicare |
$810.19
|
| Rate for Payer: Meridian Medicaid |
$465.37
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$850.70
|
| Rate for Payer: MI Amish Medical Board Commercial |
$931.72
|
| Rate for Payer: PACE Medicare |
$769.68
|
| Rate for Payer: PACE SWMI |
$810.19
|
| Rate for Payer: PHP Medicare Advantage |
$810.19
|
| Rate for Payer: Priority Health Choice Medicaid |
$443.17
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2,550.52
|
| Rate for Payer: Priority Health Medicare |
$810.19
|
| Rate for Payer: Priority Health Narrow Network |
$2,040.42
|
| Rate for Payer: Railroad Medicare Medicare |
$810.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$58.71
|
| Rate for Payer: UHC Core |
$981.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$810.19
|
| Rate for Payer: UHC Exchange |
$53.37
|
| Rate for Payer: UHC Medicare Advantage |
$834.50
|
| Rate for Payer: VA VA |
$810.19
|
|
|
INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$700.00
|
|
|
Service Code
|
CPT 64484
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$50.10 |
| Max. Negotiated Rate |
$700.00 |
| Rate for Payer: BCBS Trust/PPO |
$298.77
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$55.11
|
| Rate for Payer: UHC Core |
$700.00
|
| Rate for Payer: UHC Exchange |
$50.10
|
|
|
INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL
|
Facility
|
OP
|
$2,550.52
|
|
|
Service Code
|
CPT 64483
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$108.71 |
| Max. Negotiated Rate |
$2,550.52 |
| Rate for Payer: Aetna Medicare |
$842.60
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1,012.74
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1,012.74
|
| Rate for Payer: BCBS Complete |
$465.37
|
| Rate for Payer: BCBS MAPPO |
$810.19
|
| Rate for Payer: BCBS Trust/PPO |
$795.38
|
| Rate for Payer: BCN Medicare Advantage |
$810.19
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$810.19
|
| Rate for Payer: Mclaren Medicaid |
$443.17
|
| Rate for Payer: Mclaren Medicare |
$810.19
|
| Rate for Payer: Meridian Medicaid |
$465.37
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$850.70
|
| Rate for Payer: MI Amish Medical Board Commercial |
$931.72
|
| Rate for Payer: PACE Medicare |
$769.68
|
| Rate for Payer: PACE SWMI |
$810.19
|
| Rate for Payer: PHP Medicare Advantage |
$810.19
|
| Rate for Payer: Priority Health Choice Medicaid |
$443.17
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2,550.52
|
| Rate for Payer: Priority Health Medicare |
$810.19
|
| Rate for Payer: Priority Health Narrow Network |
$2,040.42
|
| Rate for Payer: Railroad Medicare Medicare |
$810.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$119.58
|
| Rate for Payer: UHC Core |
$981.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$810.19
|
| Rate for Payer: UHC Exchange |
$108.71
|
| Rate for Payer: UHC Medicare Advantage |
$834.50
|
| Rate for Payer: VA VA |
$810.19
|
|
|
INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRIGEMINAL NERVE, EACH BRANCH (IE, OPHTHALMIC, MAXILLARY, MANDIBULAR)
|
Facility
|
OP
|
$828.79
|
|
|
Service Code
|
CPT 64400
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$50.75 |
| Max. Negotiated Rate |
$828.79 |
| Rate for Payer: Aetna Medicare |
$273.80
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$329.09
|
| Rate for Payer: Amish Plain Church Group Commercial |
$329.09
|
| Rate for Payer: BCBS Complete |
$151.22
|
| Rate for Payer: BCBS MAPPO |
$263.27
|
| Rate for Payer: BCBS Trust/PPO |
$290.76
|
| Rate for Payer: BCN Medicare Advantage |
$263.27
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$263.27
|
| Rate for Payer: Mclaren Medicaid |
$144.01
|
| Rate for Payer: Mclaren Medicare |
$263.27
|
| Rate for Payer: Meridian Medicaid |
$151.22
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$276.43
|
| Rate for Payer: MI Amish Medical Board Commercial |
$302.76
|
| Rate for Payer: PACE Medicare |
$250.11
|
| Rate for Payer: PACE SWMI |
$263.27
|
| Rate for Payer: PHP Medicare Advantage |
$263.27
|
| Rate for Payer: Priority Health Choice Medicaid |
$144.01
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$828.79
|
| Rate for Payer: Priority Health Medicare |
$263.27
|
| Rate for Payer: Priority Health Narrow Network |
$663.03
|
| Rate for Payer: Railroad Medicare Medicare |
$263.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$55.82
|
| Rate for Payer: UHC Core |
$700.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$263.27
|
| Rate for Payer: UHC Exchange |
$50.75
|
| Rate for Payer: UHC Medicare Advantage |
$271.17
|
| Rate for Payer: VA VA |
$263.27
|
|
|
INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$700.00
|
|
|
Service Code
|
CPT 64494
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$49.44 |
| Max. Negotiated Rate |
$700.00 |
| Rate for Payer: BCBS Trust/PPO |
$293.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$54.38
|
| Rate for Payer: UHC Core |
$700.00
|
| Rate for Payer: UHC Exchange |
$49.44
|
|
|
INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SINGLE LEVEL
|
Facility
|
OP
|
$2,550.52
|
|
|
Service Code
|
CPT 64493
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$88.41 |
| Max. Negotiated Rate |
$2,550.52 |
| Rate for Payer: Aetna Medicare |
$842.60
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1,012.74
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1,012.74
|
| Rate for Payer: BCBS Complete |
$465.37
|
| Rate for Payer: BCBS MAPPO |
$810.19
|
| Rate for Payer: BCBS Trust/PPO |
$975.43
|
| Rate for Payer: BCN Medicare Advantage |
$810.19
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$810.19
|
| Rate for Payer: Mclaren Medicaid |
$443.17
|
| Rate for Payer: Mclaren Medicare |
$810.19
|
| Rate for Payer: Meridian Medicaid |
$465.37
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$850.70
|
| Rate for Payer: MI Amish Medical Board Commercial |
$931.72
|
| Rate for Payer: PACE Medicare |
$769.68
|
| Rate for Payer: PACE SWMI |
$810.19
|
| Rate for Payer: PHP Medicare Advantage |
$810.19
|
| Rate for Payer: Priority Health Choice Medicaid |
$443.17
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2,550.52
|
| Rate for Payer: Priority Health Medicare |
$810.19
|
| Rate for Payer: Priority Health Narrow Network |
$2,040.42
|
| Rate for Payer: Railroad Medicare Medicare |
$810.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$97.25
|
| Rate for Payer: UHC Core |
$981.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$810.19
|
| Rate for Payer: UHC Exchange |
$88.41
|
| Rate for Payer: UHC Medicare Advantage |
$834.50
|
| Rate for Payer: VA VA |
$810.19
|
|
|
INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$700.00
|
|
|
Service Code
|
CPT 64495
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$50.43 |
| Max. Negotiated Rate |
$700.00 |
| Rate for Payer: BCBS Trust/PPO |
$295.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$55.47
|
| Rate for Payer: UHC Core |
$700.00
|
| Rate for Payer: UHC Exchange |
$50.43
|
|
|
INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, LUMBAR OR SACRAL (CAUDAL); WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)
|
Facility
|
OP
|
$1,935.09
|
|
|
Service Code
|
CPT 62323
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$96.92 |
| Max. Negotiated Rate |
$1,935.09 |
| Rate for Payer: Aetna Medicare |
$639.29
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$768.38
|
| Rate for Payer: Amish Plain Church Group Commercial |
$768.38
|
| Rate for Payer: BCBS Complete |
$353.08
|
| Rate for Payer: BCBS MAPPO |
$614.70
|
| Rate for Payer: BCBS Trust/PPO |
$631.79
|
| Rate for Payer: BCN Medicare Advantage |
$614.70
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$614.70
|
| Rate for Payer: Mclaren Medicaid |
$336.24
|
| Rate for Payer: Mclaren Medicare |
$614.70
|
| Rate for Payer: Meridian Medicaid |
$353.08
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$645.44
|
| Rate for Payer: MI Amish Medical Board Commercial |
$706.90
|
| Rate for Payer: PACE Medicare |
$583.96
|
| Rate for Payer: PACE SWMI |
$614.70
|
| Rate for Payer: PHP Medicare Advantage |
$614.70
|
| Rate for Payer: Priority Health Choice Medicaid |
$336.24
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,935.09
|
| Rate for Payer: Priority Health Medicare |
$614.70
|
| Rate for Payer: Priority Health Narrow Network |
$1,548.07
|
| Rate for Payer: Railroad Medicare Medicare |
$614.70
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$106.61
|
| Rate for Payer: UHC Core |
$981.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$614.70
|
| Rate for Payer: UHC Exchange |
$96.92
|
| Rate for Payer: UHC Medicare Advantage |
$633.14
|
| Rate for Payer: VA VA |
$614.70
|
|
|
INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, LUMBAR OR SACRAL (CAUDAL); WITHOUT IMAGING GUIDANCE
|
Facility
|
OP
|
$2,550.52
|
|
|
Service Code
|
CPT 62322
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$77.28 |
| Max. Negotiated Rate |
$2,550.52 |
| Rate for Payer: Aetna Medicare |
$842.60
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1,012.74
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1,012.74
|
| Rate for Payer: BCBS Complete |
$465.37
|
| Rate for Payer: BCBS MAPPO |
$810.19
|
| Rate for Payer: BCBS Trust/PPO |
$532.44
|
| Rate for Payer: BCN Medicare Advantage |
$810.19
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$810.19
|
| Rate for Payer: Mclaren Medicaid |
$443.17
|
| Rate for Payer: Mclaren Medicare |
$810.19
|
| Rate for Payer: Meridian Medicaid |
$465.37
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$850.70
|
| Rate for Payer: MI Amish Medical Board Commercial |
$931.72
|
| Rate for Payer: PACE Medicare |
$769.68
|
| Rate for Payer: PACE SWMI |
$810.19
|
| Rate for Payer: PHP Medicare Advantage |
$810.19
|
| Rate for Payer: Priority Health Choice Medicaid |
$443.17
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2,550.52
|
| Rate for Payer: Priority Health Medicare |
$810.19
|
| Rate for Payer: Priority Health Narrow Network |
$2,040.42
|
| Rate for Payer: Railroad Medicare Medicare |
$810.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$85.01
|
| Rate for Payer: UHC Core |
$981.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$810.19
|
| Rate for Payer: UHC Exchange |
$77.28
|
| Rate for Payer: UHC Medicare Advantage |
$834.50
|
| Rate for Payer: VA VA |
$810.19
|
|
|
INJECTION(S) OF SCLEROSANT FOR SPIDER VEINS (TELANGIECTASIA), LIMB OR TRUNK
|
Facility
|
OP
|
$1,115.78
|
|
|
Service Code
|
CPT 36468
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$136.36 |
| Max. Negotiated Rate |
$1,115.78 |
| Rate for Payer: Aetna Medicare |
$368.61
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$443.04
|
| Rate for Payer: Amish Plain Church Group Commercial |
$443.04
|
| Rate for Payer: BCBS Complete |
$203.58
|
| Rate for Payer: BCBS MAPPO |
$354.43
|
| Rate for Payer: BCBS Trust/PPO |
$136.36
|
| Rate for Payer: BCN Medicare Advantage |
$354.43
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$354.43
|
| Rate for Payer: Mclaren Medicaid |
$193.87
|
| Rate for Payer: Mclaren Medicare |
$354.43
|
| Rate for Payer: Meridian Medicaid |
$203.58
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$372.15
|
| Rate for Payer: MI Amish Medical Board Commercial |
$407.59
|
| Rate for Payer: PACE Medicare |
$336.71
|
| Rate for Payer: PACE SWMI |
$354.43
|
| Rate for Payer: PHP Medicare Advantage |
$354.43
|
| Rate for Payer: Priority Health Choice Medicaid |
$193.87
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,115.78
|
| Rate for Payer: Priority Health Medicare |
$354.43
|
| Rate for Payer: Priority Health Narrow Network |
$892.62
|
| Rate for Payer: Railroad Medicare Medicare |
$354.43
|
| Rate for Payer: UHC Core |
$700.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$354.43
|
| Rate for Payer: UHC Medicare Advantage |
$365.06
|
| Rate for Payer: VA VA |
$354.43
|
|
|
INJECTION(S), PLATELET RICH PLASMA, ANY SITE, INCLUDING IMAGE GUIDANCE, HARVESTING AND PREPARATION WHEN PERFORMED
|
Facility
|
OP
|
$1,114.93
|
|
|
Service Code
|
CPT 0232T
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$193.73 |
| Max. Negotiated Rate |
$1,114.93 |
| Rate for Payer: Aetna Medicare |
$368.33
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$442.70
|
| Rate for Payer: Amish Plain Church Group Commercial |
$442.70
|
| Rate for Payer: BCBS Complete |
$203.43
|
| Rate for Payer: BCBS MAPPO |
$354.16
|
| Rate for Payer: BCN Medicare Advantage |
$354.16
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$354.16
|
| Rate for Payer: Mclaren Medicaid |
$193.73
|
| Rate for Payer: Mclaren Medicare |
$354.16
|
| Rate for Payer: Meridian Medicaid |
$203.43
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$371.87
|
| Rate for Payer: MI Amish Medical Board Commercial |
$407.28
|
| Rate for Payer: PACE Medicare |
$336.45
|
| Rate for Payer: PACE SWMI |
$354.16
|
| Rate for Payer: PHP Medicare Advantage |
$354.16
|
| Rate for Payer: Priority Health Choice Medicaid |
$193.73
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,114.93
|
| Rate for Payer: Priority Health Medicare |
$354.16
|
| Rate for Payer: Priority Health Narrow Network |
$891.94
|
| Rate for Payer: Railroad Medicare Medicare |
$354.16
|
| Rate for Payer: UHC Core |
$700.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$354.16
|
| Rate for Payer: UHC Medicare Advantage |
$364.78
|
| Rate for Payer: VA VA |
$354.16
|
|
|
INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)
|
Facility
|
OP
|
$828.79
|
|
|
Service Code
|
CPT 20552
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$36.02 |
| Max. Negotiated Rate |
$828.79 |
| Rate for Payer: Aetna Medicare |
$273.80
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$329.09
|
| Rate for Payer: Amish Plain Church Group Commercial |
$329.09
|
| Rate for Payer: BCBS Complete |
$151.22
|
| Rate for Payer: BCBS MAPPO |
$263.27
|
| Rate for Payer: BCBS Trust/PPO |
$290.76
|
| Rate for Payer: BCN Medicare Advantage |
$263.27
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$263.27
|
| Rate for Payer: Mclaren Medicaid |
$144.01
|
| Rate for Payer: Mclaren Medicare |
$263.27
|
| Rate for Payer: Meridian Medicaid |
$151.22
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$276.43
|
| Rate for Payer: MI Amish Medical Board Commercial |
$302.76
|
| Rate for Payer: PACE Medicare |
$250.11
|
| Rate for Payer: PACE SWMI |
$263.27
|
| Rate for Payer: PHP Medicare Advantage |
$263.27
|
| Rate for Payer: Priority Health Choice Medicaid |
$144.01
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$828.79
|
| Rate for Payer: Priority Health Medicare |
$263.27
|
| Rate for Payer: Priority Health Narrow Network |
$663.03
|
| Rate for Payer: Railroad Medicare Medicare |
$263.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$39.62
|
| Rate for Payer: UHC Core |
$700.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$263.27
|
| Rate for Payer: UHC Exchange |
$36.02
|
| Rate for Payer: UHC Medicare Advantage |
$271.17
|
| Rate for Payer: VA VA |
$263.27
|
|
