|
HC DILATOR SIZE 12
|
Facility
|
IP
|
$33.89
|
|
| Hospital Charge Code |
27000055
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$23.72 |
| Max. Negotiated Rate |
$33.89 |
| Rate for Payer: Aetna Commercial |
$30.50
|
| Rate for Payer: ASR ASR |
$32.87
|
| Rate for Payer: BCBS Trust/PPO |
$26.27
|
| Rate for Payer: BCN Commercial |
$26.27
|
| Rate for Payer: Cash Price |
$27.11
|
| Rate for Payer: Cofinity Commercial |
$31.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$27.11
|
| Rate for Payer: Healthscope Commercial |
$33.89
|
| Rate for Payer: Healthscope Whirlpool |
$32.87
|
| Rate for Payer: Mclaren Commercial |
$30.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$28.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$23.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$29.82
|
|
|
HC DILATOR SIZE 7
|
Facility
|
OP
|
$24.80
|
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$9.92 |
| Max. Negotiated Rate |
$24.80 |
| Rate for Payer: Aetna Commercial |
$22.32
|
| Rate for Payer: ASR ASR |
$24.06
|
| Rate for Payer: BCBS Complete |
$9.92
|
| Rate for Payer: BCBS Trust/PPO |
$19.23
|
| Rate for Payer: BCN Commercial |
$19.23
|
| Rate for Payer: Cash Price |
$19.84
|
| Rate for Payer: Cofinity Commercial |
$23.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.84
|
| Rate for Payer: Healthscope Commercial |
$24.80
|
| Rate for Payer: Healthscope Whirlpool |
$24.06
|
| Rate for Payer: Mclaren Commercial |
$22.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.36
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$22.57
|
| Rate for Payer: Priority Health Narrow Network |
$17.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$21.82
|
|
|
HC DILATOR SIZE 7
|
Facility
|
IP
|
$24.80
|
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$17.36 |
| Max. Negotiated Rate |
$24.80 |
| Rate for Payer: Aetna Commercial |
$22.32
|
| Rate for Payer: ASR ASR |
$24.06
|
| Rate for Payer: BCBS Trust/PPO |
$19.23
|
| Rate for Payer: BCN Commercial |
$19.23
|
| Rate for Payer: Cash Price |
$19.84
|
| Rate for Payer: Cofinity Commercial |
$23.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.84
|
| Rate for Payer: Healthscope Commercial |
$24.80
|
| Rate for Payer: Healthscope Whirlpool |
$24.06
|
| Rate for Payer: Mclaren Commercial |
$22.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.36
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$21.82
|
|
|
HC DILATOR SIZE 9
|
Facility
|
IP
|
$24.80
|
|
| Hospital Charge Code |
27000057
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$17.36 |
| Max. Negotiated Rate |
$24.80 |
| Rate for Payer: Aetna Commercial |
$22.32
|
| Rate for Payer: ASR ASR |
$24.06
|
| Rate for Payer: BCBS Trust/PPO |
$19.23
|
| Rate for Payer: BCN Commercial |
$19.23
|
| Rate for Payer: Cash Price |
$19.84
|
| Rate for Payer: Cofinity Commercial |
$23.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.84
|
| Rate for Payer: Healthscope Commercial |
$24.80
|
| Rate for Payer: Healthscope Whirlpool |
$24.06
|
| Rate for Payer: Mclaren Commercial |
$22.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.36
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$21.82
|
|
|
HC DILATOR SIZE 9
|
Facility
|
OP
|
$24.80
|
|
| Hospital Charge Code |
27000057
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$9.92 |
| Max. Negotiated Rate |
$24.80 |
| Rate for Payer: Aetna Commercial |
$22.32
|
| Rate for Payer: ASR ASR |
$24.06
|
| Rate for Payer: BCBS Complete |
$9.92
|
| Rate for Payer: BCBS Trust/PPO |
$19.23
|
| Rate for Payer: BCN Commercial |
$19.23
|
| Rate for Payer: Cash Price |
$19.84
|
| Rate for Payer: Cofinity Commercial |
$23.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.84
|
| Rate for Payer: Healthscope Commercial |
$24.80
|
| Rate for Payer: Healthscope Whirlpool |
$24.06
|
| Rate for Payer: Mclaren Commercial |
$22.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.36
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$22.57
|
| Rate for Payer: Priority Health Narrow Network |
$17.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$21.82
|
|
|
HC DIL PERC EXISTING TRACT INCLUDE NEW ACCESS
|
Facility
|
OP
|
$4,477.80
|
|
|
Service Code
|
CPT 50437
|
| Hospital Charge Code |
32000329
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1,695.03 |
| Max. Negotiated Rate |
$4,477.80 |
| Rate for Payer: Aetna Commercial |
$4,030.02
|
| Rate for Payer: Aetna Medicare |
$3,098.77
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,873.46
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,873.46
|
| Rate for Payer: ASR ASR |
$4,343.47
|
| Rate for Payer: BCBS Complete |
$1,779.93
|
| Rate for Payer: BCBS MAPPO |
$3,098.77
|
| Rate for Payer: BCBS Trust/PPO |
$3,471.64
|
| Rate for Payer: BCN Commercial |
$3,471.64
|
| Rate for Payer: BCN Medicare Advantage |
$3,098.77
|
| Rate for Payer: Cash Price |
$3,582.24
|
| Rate for Payer: Cash Price |
$3,582.24
|
| Rate for Payer: Cofinity Commercial |
$4,209.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,582.24
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,098.77
|
| Rate for Payer: Healthscope Commercial |
$4,477.80
|
| Rate for Payer: Healthscope Whirlpool |
$4,343.47
|
| Rate for Payer: Humana Choice PPO Medicare |
$3,098.77
|
| Rate for Payer: Mclaren Commercial |
$4,030.02
|
| Rate for Payer: Mclaren Medicaid |
$1,695.03
|
| Rate for Payer: Mclaren Medicare |
$3,098.77
|
| Rate for Payer: Meridian Medicaid |
$1,779.93
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$3,253.71
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,563.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3,806.13
|
| Rate for Payer: PACE Medicare |
$2,943.83
|
| Rate for Payer: PACE SWMI |
$3,098.77
|
| Rate for Payer: PHP Commercial |
$3,408.65
|
| Rate for Payer: PHP Medicaid |
$1,695.03
|
| Rate for Payer: PHP Medicare Advantage |
$3,098.77
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,695.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,134.46
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$3,131.74
|
| Rate for Payer: Priority Health Medicare |
$3,098.77
|
| Rate for Payer: Priority Health Narrow Network |
$2,505.39
|
| Rate for Payer: Railroad Medicare Medicare |
$3,098.77
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3,940.46
|
| Rate for Payer: UHC Medicare Advantage |
$3,191.73
|
| Rate for Payer: VA VA |
$3,098.77
|
|
|
HC DIL PERC EXISTING TRACT INCLUDE NEW ACCESS
|
Facility
|
IP
|
$4,477.80
|
|
|
Service Code
|
CPT 50437
|
| Hospital Charge Code |
32000329
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$3,134.46 |
| Max. Negotiated Rate |
$4,477.80 |
| Rate for Payer: Aetna Commercial |
$4,030.02
|
| Rate for Payer: ASR ASR |
$4,343.47
|
| Rate for Payer: BCBS Trust/PPO |
$3,471.64
|
| Rate for Payer: BCN Commercial |
$3,471.64
|
| Rate for Payer: Cash Price |
$3,582.24
|
| Rate for Payer: Cofinity Commercial |
$4,209.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,582.24
|
| Rate for Payer: Healthscope Commercial |
$4,477.80
|
| Rate for Payer: Healthscope Whirlpool |
$4,343.47
|
| Rate for Payer: Mclaren Commercial |
$4,030.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3,806.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,134.46
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3,940.46
|
|
|
HC DIPHTHERIA/TETANUS AB PANEL, S
|
Facility
|
IP
|
$44.50
|
|
|
Service Code
|
CPT 86317
|
| Hospital Charge Code |
30200506
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$31.15 |
| Max. Negotiated Rate |
$44.50 |
| Rate for Payer: Aetna Commercial |
$40.05
|
| Rate for Payer: ASR ASR |
$43.16
|
| Rate for Payer: BCBS Trust/PPO |
$34.50
|
| Rate for Payer: BCN Commercial |
$34.50
|
| Rate for Payer: Cash Price |
$35.60
|
| Rate for Payer: Cofinity Commercial |
$41.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$35.60
|
| Rate for Payer: Healthscope Commercial |
$44.50
|
| Rate for Payer: Healthscope Whirlpool |
$43.16
|
| Rate for Payer: Mclaren Commercial |
$40.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$37.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$31.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$39.16
|
|
|
HC DIPHTHERIA/TETANUS AB PANEL, S
|
Facility
|
OP
|
$44.50
|
|
|
Service Code
|
CPT 86317
|
| Hospital Charge Code |
30200506
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$8.20 |
| Max. Negotiated Rate |
$44.50 |
| Rate for Payer: Aetna Commercial |
$40.05
|
| Rate for Payer: Aetna Medicare |
$14.99
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$18.74
|
| Rate for Payer: Amish Plain Church Group Commercial |
$18.74
|
| Rate for Payer: ASR ASR |
$43.16
|
| Rate for Payer: BCBS Complete |
$8.61
|
| Rate for Payer: BCBS MAPPO |
$14.99
|
| Rate for Payer: BCBS Trust/PPO |
$34.50
|
| Rate for Payer: BCN Commercial |
$34.50
|
| Rate for Payer: BCN Medicare Advantage |
$14.99
|
| Rate for Payer: Cash Price |
$35.60
|
| Rate for Payer: Cash Price |
$35.60
|
| Rate for Payer: Cofinity Commercial |
$41.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$35.60
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$14.99
|
| Rate for Payer: Healthscope Commercial |
$44.50
|
| Rate for Payer: Healthscope Whirlpool |
$43.16
|
| Rate for Payer: Humana Choice PPO Medicare |
$14.99
|
| Rate for Payer: Mclaren Commercial |
$40.05
|
| Rate for Payer: Mclaren Medicaid |
$8.20
|
| Rate for Payer: Mclaren Medicare |
$14.99
|
| Rate for Payer: Meridian Medicaid |
$8.61
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$15.74
|
| Rate for Payer: MI Amish Medical Board Commercial |
$17.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$37.82
|
| Rate for Payer: PACE Medicare |
$14.24
|
| Rate for Payer: PACE SWMI |
$14.99
|
| Rate for Payer: PHP Commercial |
$16.49
|
| Rate for Payer: PHP Medicaid |
$8.20
|
| Rate for Payer: PHP Medicare Advantage |
$14.99
|
| Rate for Payer: Priority Health Choice Medicaid |
$8.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$31.15
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$40.50
|
| Rate for Payer: Priority Health Medicare |
$14.99
|
| Rate for Payer: Priority Health Narrow Network |
$31.60
|
| Rate for Payer: Railroad Medicare Medicare |
$14.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$39.16
|
| Rate for Payer: UHC Medicare Advantage |
$15.44
|
| Rate for Payer: VA VA |
$14.99
|
|
|
HC DIP, TET TOX, HAEMO INFLU TYPE B, INACTIV POLIO VAC, (DTAP-IPV/HIB) IM
|
Facility
|
IP
|
$121.18
|
|
|
Service Code
|
CPT 90698
|
| Hospital Charge Code |
63600080
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$84.83 |
| Max. Negotiated Rate |
$121.18 |
| Rate for Payer: Aetna Commercial |
$109.06
|
| Rate for Payer: ASR ASR |
$117.54
|
| Rate for Payer: BCBS Trust/PPO |
$93.95
|
| Rate for Payer: BCN Commercial |
$93.95
|
| Rate for Payer: Cash Price |
$96.94
|
| Rate for Payer: Cofinity Commercial |
$113.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$96.94
|
| Rate for Payer: Healthscope Commercial |
$121.18
|
| Rate for Payer: Healthscope Whirlpool |
$117.54
|
| Rate for Payer: Mclaren Commercial |
$109.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$103.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$84.83
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$106.64
|
|
|
HC DIP, TET TOX, HAEMO INFLU TYPE B, INACTIV POLIO VAC, (DTAP-IPV/HIB) IM
|
Facility
|
OP
|
$121.18
|
|
|
Service Code
|
CPT 90698
|
| Hospital Charge Code |
63600080
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.47 |
| Max. Negotiated Rate |
$121.18 |
| Rate for Payer: Aetna Commercial |
$109.06
|
| Rate for Payer: ASR ASR |
$117.54
|
| Rate for Payer: BCBS Complete |
$48.47
|
| Rate for Payer: BCBS Trust/PPO |
$93.95
|
| Rate for Payer: BCN Commercial |
$93.95
|
| Rate for Payer: Cash Price |
$96.94
|
| Rate for Payer: Cofinity Commercial |
$113.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$96.94
|
| Rate for Payer: Healthscope Commercial |
$121.18
|
| Rate for Payer: Healthscope Whirlpool |
$117.54
|
| Rate for Payer: Mclaren Commercial |
$109.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$103.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$84.83
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$110.27
|
| Rate for Payer: Priority Health Narrow Network |
$86.04
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$106.64
|
|
|
HC DIPTH, TET TOX, AND ACELLUEAR PERTUSSIS VAC (DTAP), LESS THAN 7 YRS IM
|
Facility
|
OP
|
$52.73
|
|
|
Service Code
|
CPT 90700
|
| Hospital Charge Code |
63600081
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.09 |
| Max. Negotiated Rate |
$52.73 |
| Rate for Payer: Aetna Commercial |
$47.46
|
| Rate for Payer: ASR ASR |
$51.15
|
| Rate for Payer: BCBS Complete |
$21.09
|
| Rate for Payer: BCBS Trust/PPO |
$40.88
|
| Rate for Payer: BCN Commercial |
$40.88
|
| Rate for Payer: Cash Price |
$42.18
|
| Rate for Payer: Cofinity Commercial |
$49.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$42.18
|
| Rate for Payer: Healthscope Commercial |
$52.73
|
| Rate for Payer: Healthscope Whirlpool |
$51.15
|
| Rate for Payer: Mclaren Commercial |
$47.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$44.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$36.91
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$47.98
|
| Rate for Payer: Priority Health Narrow Network |
$37.44
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$46.40
|
|
|
HC DIPTH, TET TOX, AND ACELLUEAR PERTUSSIS VAC (DTAP), LESS THAN 7 YRS IM
|
Facility
|
IP
|
$52.73
|
|
|
Service Code
|
CPT 90700
|
| Hospital Charge Code |
63600081
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.91 |
| Max. Negotiated Rate |
$52.73 |
| Rate for Payer: Aetna Commercial |
$47.46
|
| Rate for Payer: ASR ASR |
$51.15
|
| Rate for Payer: BCBS Trust/PPO |
$40.88
|
| Rate for Payer: BCN Commercial |
$40.88
|
| Rate for Payer: Cash Price |
$42.18
|
| Rate for Payer: Cofinity Commercial |
$49.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$42.18
|
| Rate for Payer: Healthscope Commercial |
$52.73
|
| Rate for Payer: Healthscope Whirlpool |
$51.15
|
| Rate for Payer: Mclaren Commercial |
$47.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$44.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$36.91
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$46.40
|
|
|
HC DIRECT ADMIT TO OBS
|
Facility
|
OP
|
$151.79
|
|
|
Service Code
|
HCPCS G0379
|
| Hospital Charge Code |
76200001
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$85.98 |
| Max. Negotiated Rate |
$713.68 |
| Rate for Payer: Aetna Commercial |
$136.61
|
| Rate for Payer: Aetna Medicare |
$570.94
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$713.68
|
| Rate for Payer: Amish Plain Church Group Commercial |
$713.68
|
| Rate for Payer: ASR ASR |
$147.24
|
| Rate for Payer: BCBS Complete |
$327.95
|
| Rate for Payer: BCBS MAPPO |
$570.94
|
| Rate for Payer: BCBS Trust/PPO |
$117.68
|
| Rate for Payer: BCN Commercial |
$117.68
|
| Rate for Payer: BCN Medicare Advantage |
$570.94
|
| Rate for Payer: Cash Price |
$121.43
|
| Rate for Payer: Cash Price |
$121.43
|
| Rate for Payer: Cofinity Commercial |
$142.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$121.43
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$570.94
|
| Rate for Payer: Healthscope Commercial |
$151.79
|
| Rate for Payer: Healthscope Whirlpool |
$147.24
|
| Rate for Payer: Humana Choice PPO Medicare |
$570.94
|
| Rate for Payer: Mclaren Commercial |
$136.61
|
| Rate for Payer: Mclaren Medicaid |
$312.30
|
| Rate for Payer: Mclaren Medicare |
$570.94
|
| Rate for Payer: Meridian Medicaid |
$327.95
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$599.49
|
| Rate for Payer: MI Amish Medical Board Commercial |
$656.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$129.02
|
| Rate for Payer: PACE Medicare |
$542.39
|
| Rate for Payer: PACE SWMI |
$570.94
|
| Rate for Payer: PHP Commercial |
$628.03
|
| Rate for Payer: PHP Medicaid |
$312.30
|
| Rate for Payer: PHP Medicare Advantage |
$570.94
|
| Rate for Payer: Priority Health Choice Medicaid |
$312.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$106.25
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$107.48
|
| Rate for Payer: Priority Health Medicare |
$570.94
|
| Rate for Payer: Priority Health Narrow Network |
$85.98
|
| Rate for Payer: Railroad Medicare Medicare |
$570.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$133.58
|
| Rate for Payer: UHC Medicare Advantage |
$588.07
|
| Rate for Payer: VA VA |
$570.94
|
|
|
HC DIRECT ADMIT TO OBS
|
Facility
|
IP
|
$151.79
|
|
|
Service Code
|
HCPCS G0379
|
| Hospital Charge Code |
76200001
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$106.25 |
| Max. Negotiated Rate |
$151.79 |
| Rate for Payer: Aetna Commercial |
$136.61
|
| Rate for Payer: ASR ASR |
$147.24
|
| Rate for Payer: BCBS Trust/PPO |
$117.68
|
| Rate for Payer: BCN Commercial |
$117.68
|
| Rate for Payer: Cash Price |
$121.43
|
| Rate for Payer: Cofinity Commercial |
$142.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$121.43
|
| Rate for Payer: Healthscope Commercial |
$151.79
|
| Rate for Payer: Healthscope Whirlpool |
$147.24
|
| Rate for Payer: Mclaren Commercial |
$136.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$129.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$106.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$133.58
|
|
|
HC DIRECT COOMBS
|
Facility
|
IP
|
$64.36
|
|
|
Service Code
|
CPT 86880
|
| Hospital Charge Code |
30200343
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$45.05 |
| Max. Negotiated Rate |
$64.36 |
| Rate for Payer: Aetna Commercial |
$57.92
|
| Rate for Payer: ASR ASR |
$62.43
|
| Rate for Payer: BCBS Trust/PPO |
$49.90
|
| Rate for Payer: BCN Commercial |
$49.90
|
| Rate for Payer: Cash Price |
$51.49
|
| Rate for Payer: Cofinity Commercial |
$60.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$51.49
|
| Rate for Payer: Healthscope Commercial |
$64.36
|
| Rate for Payer: Healthscope Whirlpool |
$62.43
|
| Rate for Payer: Mclaren Commercial |
$57.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$54.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.05
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$56.64
|
|
|
HC DIRECT COOMBS
|
Facility
|
OP
|
$64.36
|
|
|
Service Code
|
CPT 86880
|
| Hospital Charge Code |
30200343
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$29.74 |
| Max. Negotiated Rate |
$67.96 |
| Rate for Payer: Aetna Commercial |
$57.92
|
| Rate for Payer: Aetna Medicare |
$54.37
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$67.96
|
| Rate for Payer: Amish Plain Church Group Commercial |
$67.96
|
| Rate for Payer: ASR ASR |
$62.43
|
| Rate for Payer: BCBS Complete |
$31.23
|
| Rate for Payer: BCBS MAPPO |
$54.37
|
| Rate for Payer: BCBS Trust/PPO |
$49.90
|
| Rate for Payer: BCN Commercial |
$49.90
|
| Rate for Payer: BCN Medicare Advantage |
$54.37
|
| Rate for Payer: Cash Price |
$51.49
|
| Rate for Payer: Cash Price |
$51.49
|
| Rate for Payer: Cofinity Commercial |
$60.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$51.49
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$54.37
|
| Rate for Payer: Healthscope Commercial |
$64.36
|
| Rate for Payer: Healthscope Whirlpool |
$62.43
|
| Rate for Payer: Humana Choice PPO Medicare |
$54.37
|
| Rate for Payer: Mclaren Commercial |
$57.92
|
| Rate for Payer: Mclaren Medicaid |
$29.74
|
| Rate for Payer: Mclaren Medicare |
$54.37
|
| Rate for Payer: Meridian Medicaid |
$31.23
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$57.09
|
| Rate for Payer: MI Amish Medical Board Commercial |
$62.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$54.71
|
| Rate for Payer: PACE Medicare |
$51.65
|
| Rate for Payer: PACE SWMI |
$54.37
|
| Rate for Payer: PHP Commercial |
$59.81
|
| Rate for Payer: PHP Medicaid |
$29.74
|
| Rate for Payer: PHP Medicare Advantage |
$54.37
|
| Rate for Payer: Priority Health Choice Medicaid |
$29.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.05
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$64.65
|
| Rate for Payer: Priority Health Medicare |
$54.37
|
| Rate for Payer: Priority Health Narrow Network |
$51.72
|
| Rate for Payer: Railroad Medicare Medicare |
$54.37
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$56.64
|
| Rate for Payer: UHC Medicare Advantage |
$56.00
|
| Rate for Payer: VA VA |
$54.37
|
|
|
HC DISACCHARIDASE ANALYSIS
|
Facility
|
IP
|
$150.00
|
|
|
Service Code
|
CPT 82657
|
| Hospital Charge Code |
30100755
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$105.00 |
| Max. Negotiated Rate |
$150.00 |
| Rate for Payer: Aetna Commercial |
$135.00
|
| Rate for Payer: ASR ASR |
$145.50
|
| Rate for Payer: BCBS Trust/PPO |
$116.30
|
| Rate for Payer: BCN Commercial |
$116.30
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Cofinity Commercial |
$141.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$120.00
|
| Rate for Payer: Healthscope Commercial |
$150.00
|
| Rate for Payer: Healthscope Whirlpool |
$145.50
|
| Rate for Payer: Mclaren Commercial |
$135.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$127.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$105.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$132.00
|
|
|
HC DISACCHARIDASE ANALYSIS
|
Facility
|
OP
|
$150.00
|
|
|
Service Code
|
CPT 82657
|
| Hospital Charge Code |
30100755
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$12.13 |
| Max. Negotiated Rate |
$150.00 |
| Rate for Payer: Aetna Commercial |
$135.00
|
| Rate for Payer: Aetna Medicare |
$22.17
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$27.71
|
| Rate for Payer: Amish Plain Church Group Commercial |
$27.71
|
| Rate for Payer: ASR ASR |
$145.50
|
| Rate for Payer: BCBS Complete |
$12.73
|
| Rate for Payer: BCBS MAPPO |
$22.17
|
| Rate for Payer: BCBS Trust/PPO |
$116.30
|
| Rate for Payer: BCN Commercial |
$116.30
|
| Rate for Payer: BCN Medicare Advantage |
$22.17
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Cofinity Commercial |
$141.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$120.00
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$22.17
|
| Rate for Payer: Healthscope Commercial |
$150.00
|
| Rate for Payer: Healthscope Whirlpool |
$145.50
|
| Rate for Payer: Humana Choice PPO Medicare |
$22.17
|
| Rate for Payer: Mclaren Commercial |
$135.00
|
| Rate for Payer: Mclaren Medicaid |
$12.13
|
| Rate for Payer: Mclaren Medicare |
$22.17
|
| Rate for Payer: Meridian Medicaid |
$12.73
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$23.28
|
| Rate for Payer: MI Amish Medical Board Commercial |
$25.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$127.50
|
| Rate for Payer: PACE Medicare |
$21.06
|
| Rate for Payer: PACE SWMI |
$22.17
|
| Rate for Payer: PHP Commercial |
$24.39
|
| Rate for Payer: PHP Medicaid |
$12.13
|
| Rate for Payer: PHP Medicare Advantage |
$22.17
|
| Rate for Payer: Priority Health Choice Medicaid |
$12.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$105.00
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$136.50
|
| Rate for Payer: Priority Health Medicare |
$22.17
|
| Rate for Payer: Priority Health Narrow Network |
$106.50
|
| Rate for Payer: Railroad Medicare Medicare |
$22.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$132.00
|
| Rate for Payer: UHC Medicare Advantage |
$22.84
|
| Rate for Payer: VA VA |
$22.17
|
|
|
HC DISP FEE CONTRALATERAL BINAURAL
|
Facility
|
IP
|
$475.00
|
|
|
Service Code
|
CPT V5240
|
| Hospital Charge Code |
27100022
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$332.50 |
| Max. Negotiated Rate |
$475.00 |
| Rate for Payer: Aetna Commercial |
$427.50
|
| Rate for Payer: ASR ASR |
$460.75
|
| Rate for Payer: BCBS Trust/PPO |
$368.27
|
| Rate for Payer: BCN Commercial |
$368.27
|
| Rate for Payer: Cash Price |
$380.00
|
| Rate for Payer: Cofinity Commercial |
$446.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$380.00
|
| Rate for Payer: Healthscope Commercial |
$475.00
|
| Rate for Payer: Healthscope Whirlpool |
$460.75
|
| Rate for Payer: Mclaren Commercial |
$427.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$403.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$332.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$418.00
|
|
|
HC DISP FEE CONTRALATERAL BINAURAL
|
Facility
|
OP
|
$475.00
|
|
|
Service Code
|
CPT V5240
|
| Hospital Charge Code |
27100022
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$190.00 |
| Max. Negotiated Rate |
$475.00 |
| Rate for Payer: Aetna Commercial |
$427.50
|
| Rate for Payer: ASR ASR |
$460.75
|
| Rate for Payer: BCBS Complete |
$190.00
|
| Rate for Payer: BCBS Trust/PPO |
$368.27
|
| Rate for Payer: BCN Commercial |
$368.27
|
| Rate for Payer: Cash Price |
$380.00
|
| Rate for Payer: Cofinity Commercial |
$446.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$380.00
|
| Rate for Payer: Healthscope Commercial |
$475.00
|
| Rate for Payer: Healthscope Whirlpool |
$460.75
|
| Rate for Payer: Mclaren Commercial |
$427.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$403.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$332.50
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$432.25
|
| Rate for Payer: Priority Health Narrow Network |
$337.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$418.00
|
|
|
HC DISP FEE CONTRALATERAL MONAURAL
|
Facility
|
OP
|
$275.00
|
|
|
Service Code
|
CPT V5200
|
| Hospital Charge Code |
27100021
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$110.00 |
| Max. Negotiated Rate |
$275.00 |
| Rate for Payer: Aetna Commercial |
$247.50
|
| Rate for Payer: ASR ASR |
$266.75
|
| Rate for Payer: BCBS Complete |
$110.00
|
| Rate for Payer: BCBS Trust/PPO |
$213.21
|
| Rate for Payer: BCN Commercial |
$213.21
|
| Rate for Payer: Cash Price |
$220.00
|
| Rate for Payer: Cofinity Commercial |
$258.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$220.00
|
| Rate for Payer: Healthscope Commercial |
$275.00
|
| Rate for Payer: Healthscope Whirlpool |
$266.75
|
| Rate for Payer: Mclaren Commercial |
$247.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$233.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$192.50
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$250.25
|
| Rate for Payer: Priority Health Narrow Network |
$195.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$242.00
|
|
|
HC DISP FEE CONTRALATERAL MONAURAL
|
Facility
|
IP
|
$275.00
|
|
|
Service Code
|
CPT V5200
|
| Hospital Charge Code |
27100021
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$192.50 |
| Max. Negotiated Rate |
$275.00 |
| Rate for Payer: Aetna Commercial |
$247.50
|
| Rate for Payer: ASR ASR |
$266.75
|
| Rate for Payer: BCBS Trust/PPO |
$213.21
|
| Rate for Payer: BCN Commercial |
$213.21
|
| Rate for Payer: Cash Price |
$220.00
|
| Rate for Payer: Cofinity Commercial |
$258.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$220.00
|
| Rate for Payer: Healthscope Commercial |
$275.00
|
| Rate for Payer: Healthscope Whirlpool |
$266.75
|
| Rate for Payer: Mclaren Commercial |
$247.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$233.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$192.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$242.00
|
|
|
HC DNA DOUBLE STRANDED AB
|
Facility
|
IP
|
$27.85
|
|
|
Service Code
|
CPT 86225
|
| Hospital Charge Code |
30200158
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$19.50 |
| Max. Negotiated Rate |
$27.85 |
| Rate for Payer: Aetna Commercial |
$25.06
|
| Rate for Payer: ASR ASR |
$27.01
|
| Rate for Payer: BCBS Trust/PPO |
$21.59
|
| Rate for Payer: BCN Commercial |
$21.59
|
| Rate for Payer: Cash Price |
$22.28
|
| Rate for Payer: Cofinity Commercial |
$26.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.28
|
| Rate for Payer: Healthscope Commercial |
$27.85
|
| Rate for Payer: Healthscope Whirlpool |
$27.01
|
| Rate for Payer: Mclaren Commercial |
$25.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$23.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$24.51
|
|
|
HC DNA DOUBLE STRANDED AB
|
Facility
|
OP
|
$27.85
|
|
|
Service Code
|
CPT 86225
|
| Hospital Charge Code |
30200158
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$7.52 |
| Max. Negotiated Rate |
$33.87 |
| Rate for Payer: Aetna Commercial |
$25.06
|
| Rate for Payer: Aetna Medicare |
$13.74
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$17.18
|
| Rate for Payer: Amish Plain Church Group Commercial |
$17.18
|
| Rate for Payer: ASR ASR |
$27.01
|
| Rate for Payer: BCBS Complete |
$7.89
|
| Rate for Payer: BCBS MAPPO |
$13.74
|
| Rate for Payer: BCBS Trust/PPO |
$21.59
|
| Rate for Payer: BCN Commercial |
$21.59
|
| Rate for Payer: BCN Medicare Advantage |
$13.74
|
| Rate for Payer: Cash Price |
$22.28
|
| Rate for Payer: Cash Price |
$22.28
|
| Rate for Payer: Cofinity Commercial |
$26.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.28
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$13.74
|
| Rate for Payer: Healthscope Commercial |
$27.85
|
| Rate for Payer: Healthscope Whirlpool |
$27.01
|
| Rate for Payer: Humana Choice PPO Medicare |
$13.74
|
| Rate for Payer: Mclaren Commercial |
$25.06
|
| Rate for Payer: Mclaren Medicaid |
$7.52
|
| Rate for Payer: Mclaren Medicare |
$13.74
|
| Rate for Payer: Meridian Medicaid |
$7.89
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$14.43
|
| Rate for Payer: MI Amish Medical Board Commercial |
$15.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$23.67
|
| Rate for Payer: PACE Medicare |
$13.05
|
| Rate for Payer: PACE SWMI |
$13.74
|
| Rate for Payer: PHP Commercial |
$15.11
|
| Rate for Payer: PHP Medicaid |
$7.52
|
| Rate for Payer: PHP Medicare Advantage |
$13.74
|
| Rate for Payer: Priority Health Choice Medicaid |
$7.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.50
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$33.87
|
| Rate for Payer: Priority Health Medicare |
$13.74
|
| Rate for Payer: Priority Health Narrow Network |
$27.10
|
| Rate for Payer: Railroad Medicare Medicare |
$13.74
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$24.51
|
| Rate for Payer: UHC Medicare Advantage |
$14.15
|
| Rate for Payer: VA VA |
$13.74
|
|
