|
HC COMP BURN GARM SUIT SLVLS ABV
|
Facility
|
OP
|
$326.69
|
|
|
Service Code
|
HCPCS A6512
|
| Hospital Charge Code |
98300061
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$120.88 |
| Max. Negotiated Rate |
$326.69 |
| Rate for Payer: Aetna Commercial |
$294.02
|
| Rate for Payer: Aetna Medicare |
$120.88
|
| Rate for Payer: ASR ASR |
$316.89
|
| Rate for Payer: BCBS Complete |
$130.68
|
| Rate for Payer: BCBS Trust/PPO |
$269.36
|
| Rate for Payer: BCN Commercial |
$269.36
|
| Rate for Payer: Cash Price |
$261.35
|
| Rate for Payer: Cofinity Commercial |
$307.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$261.35
|
| Rate for Payer: Healthscope Commercial |
$316.89
|
| Rate for Payer: Healthscope Whirlpool |
$326.69
|
| Rate for Payer: Mclaren Commercial |
$294.02
|
| Rate for Payer: MI Amish Medical Board Commercial |
$261.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$277.69
|
| Rate for Payer: Nomi Health Commercial |
$267.89
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$245.02
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$286.25
|
| Rate for Payer: Priority Health Narrow Network |
$229.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$287.49
|
|
|
HC COMP BURN GARM SUIT SLVLS ABV
|
Facility
|
IP
|
$326.69
|
|
|
Service Code
|
HCPCS A6512
|
| Hospital Charge Code |
98300061
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$245.02 |
| Max. Negotiated Rate |
$326.69 |
| Rate for Payer: Aetna Commercial |
$294.02
|
| Rate for Payer: ASR ASR |
$316.89
|
| Rate for Payer: BCBS Trust/PPO |
$268.28
|
| Rate for Payer: BCN Commercial |
$268.28
|
| Rate for Payer: Cash Price |
$261.35
|
| Rate for Payer: Cofinity Commercial |
$307.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$261.35
|
| Rate for Payer: Healthscope Commercial |
$316.89
|
| Rate for Payer: Healthscope Whirlpool |
$326.69
|
| Rate for Payer: Mclaren Commercial |
$294.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$277.69
|
| Rate for Payer: Nomi Health Commercial |
$267.89
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$245.02
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$287.49
|
|
|
HC COMP BURN GARM SUIT SLVLS-TWO LEGS
|
Facility
|
IP
|
$382.87
|
|
|
Service Code
|
HCPCS A6512
|
| Hospital Charge Code |
98300062
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$287.15 |
| Max. Negotiated Rate |
$382.87 |
| Rate for Payer: Aetna Commercial |
$344.58
|
| Rate for Payer: ASR ASR |
$371.38
|
| Rate for Payer: BCBS Trust/PPO |
$314.41
|
| Rate for Payer: BCN Commercial |
$314.41
|
| Rate for Payer: Cash Price |
$306.30
|
| Rate for Payer: Cofinity Commercial |
$359.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$306.30
|
| Rate for Payer: Healthscope Commercial |
$371.38
|
| Rate for Payer: Healthscope Whirlpool |
$382.87
|
| Rate for Payer: Mclaren Commercial |
$344.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$325.44
|
| Rate for Payer: Nomi Health Commercial |
$313.95
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$287.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$336.93
|
|
|
HC COMP BURN GARM SUIT SLVLS-TWO LEGS
|
Facility
|
OP
|
$382.87
|
|
|
Service Code
|
HCPCS A6512
|
| Hospital Charge Code |
98300062
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$141.66 |
| Max. Negotiated Rate |
$382.87 |
| Rate for Payer: Aetna Commercial |
$344.58
|
| Rate for Payer: Aetna Medicare |
$141.66
|
| Rate for Payer: ASR ASR |
$371.38
|
| Rate for Payer: BCBS Complete |
$153.15
|
| Rate for Payer: BCBS Trust/PPO |
$315.68
|
| Rate for Payer: BCN Commercial |
$315.68
|
| Rate for Payer: Cash Price |
$306.30
|
| Rate for Payer: Cofinity Commercial |
$359.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$306.30
|
| Rate for Payer: Healthscope Commercial |
$371.38
|
| Rate for Payer: Healthscope Whirlpool |
$382.87
|
| Rate for Payer: Mclaren Commercial |
$344.58
|
| Rate for Payer: MI Amish Medical Board Commercial |
$306.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$325.44
|
| Rate for Payer: Nomi Health Commercial |
$313.95
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$287.15
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$335.47
|
| Rate for Payer: Priority Health Narrow Network |
$268.39
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$336.93
|
|
|
HC COMP BURN GARM SUSPENDERS ATTA
|
Facility
|
IP
|
$46.82
|
|
|
Service Code
|
HCPCS A9900
|
| Hospital Charge Code |
98300063
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$35.12 |
| Max. Negotiated Rate |
$46.82 |
| Rate for Payer: Aetna Commercial |
$42.14
|
| Rate for Payer: ASR ASR |
$45.42
|
| Rate for Payer: BCBS Trust/PPO |
$38.45
|
| Rate for Payer: BCN Commercial |
$38.45
|
| Rate for Payer: Cash Price |
$37.46
|
| Rate for Payer: Cofinity Commercial |
$44.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$37.46
|
| Rate for Payer: Healthscope Commercial |
$45.42
|
| Rate for Payer: Healthscope Whirlpool |
$46.82
|
| Rate for Payer: Mclaren Commercial |
$42.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$39.80
|
| Rate for Payer: Nomi Health Commercial |
$38.39
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$35.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$41.20
|
|
|
HC COMP BURN GARM SUSPENDERS ATTA
|
Facility
|
OP
|
$46.82
|
|
|
Service Code
|
HCPCS A9900
|
| Hospital Charge Code |
98300063
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$17.32 |
| Max. Negotiated Rate |
$46.82 |
| Rate for Payer: Aetna Commercial |
$42.14
|
| Rate for Payer: Aetna Medicare |
$17.32
|
| Rate for Payer: ASR ASR |
$45.42
|
| Rate for Payer: BCBS Complete |
$18.73
|
| Rate for Payer: BCBS Trust/PPO |
$38.60
|
| Rate for Payer: BCN Commercial |
$38.60
|
| Rate for Payer: Cash Price |
$37.46
|
| Rate for Payer: Cofinity Commercial |
$44.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$37.46
|
| Rate for Payer: Healthscope Commercial |
$45.42
|
| Rate for Payer: Healthscope Whirlpool |
$46.82
|
| Rate for Payer: Mclaren Commercial |
$42.14
|
| Rate for Payer: MI Amish Medical Board Commercial |
$37.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$39.80
|
| Rate for Payer: Nomi Health Commercial |
$38.39
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$35.12
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$41.02
|
| Rate for Payer: Priority Health Narrow Network |
$32.82
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$41.20
|
|
|
HC COMP BURN GARM SUSPENDERS REMO
|
Facility
|
IP
|
$12.48
|
|
|
Service Code
|
HCPCS A9900
|
| Hospital Charge Code |
98300064
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$9.36 |
| Max. Negotiated Rate |
$12.48 |
| Rate for Payer: Aetna Commercial |
$11.23
|
| Rate for Payer: ASR ASR |
$12.11
|
| Rate for Payer: BCBS Trust/PPO |
$10.25
|
| Rate for Payer: BCN Commercial |
$10.25
|
| Rate for Payer: Cash Price |
$9.98
|
| Rate for Payer: Cofinity Commercial |
$11.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.98
|
| Rate for Payer: Healthscope Commercial |
$12.11
|
| Rate for Payer: Healthscope Whirlpool |
$12.48
|
| Rate for Payer: Mclaren Commercial |
$11.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.61
|
| Rate for Payer: Nomi Health Commercial |
$10.23
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$9.36
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$10.98
|
|
|
HC COMP BURN GARM SUSPENDERS REMO
|
Facility
|
OP
|
$12.48
|
|
|
Service Code
|
HCPCS A9900
|
| Hospital Charge Code |
98300064
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$4.62 |
| Max. Negotiated Rate |
$12.48 |
| Rate for Payer: Aetna Commercial |
$11.23
|
| Rate for Payer: Aetna Medicare |
$4.62
|
| Rate for Payer: ASR ASR |
$12.11
|
| Rate for Payer: BCBS Complete |
$4.99
|
| Rate for Payer: BCBS Trust/PPO |
$10.29
|
| Rate for Payer: BCN Commercial |
$10.29
|
| Rate for Payer: Cash Price |
$9.98
|
| Rate for Payer: Cofinity Commercial |
$11.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.98
|
| Rate for Payer: Healthscope Commercial |
$12.11
|
| Rate for Payer: Healthscope Whirlpool |
$12.48
|
| Rate for Payer: Mclaren Commercial |
$11.23
|
| Rate for Payer: MI Amish Medical Board Commercial |
$9.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.61
|
| Rate for Payer: Nomi Health Commercial |
$10.23
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$9.36
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$10.93
|
| Rate for Payer: Priority Health Narrow Network |
$8.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$10.98
|
|
|
HC COMP BURN GARM TWO LEGS PREGNA
|
Facility
|
OP
|
$260.10
|
|
|
Service Code
|
HCPCS A6512
|
| Hospital Charge Code |
98300065
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$96.24 |
| Max. Negotiated Rate |
$260.10 |
| Rate for Payer: Aetna Commercial |
$234.09
|
| Rate for Payer: Aetna Medicare |
$96.24
|
| Rate for Payer: ASR ASR |
$252.30
|
| Rate for Payer: BCBS Complete |
$104.04
|
| Rate for Payer: BCBS Trust/PPO |
$214.45
|
| Rate for Payer: BCN Commercial |
$214.45
|
| Rate for Payer: Cash Price |
$208.08
|
| Rate for Payer: Cofinity Commercial |
$244.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$208.08
|
| Rate for Payer: Healthscope Commercial |
$252.30
|
| Rate for Payer: Healthscope Whirlpool |
$260.10
|
| Rate for Payer: Mclaren Commercial |
$234.09
|
| Rate for Payer: MI Amish Medical Board Commercial |
$208.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$221.09
|
| Rate for Payer: Nomi Health Commercial |
$213.28
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$195.07
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$227.90
|
| Rate for Payer: Priority Health Narrow Network |
$182.33
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$228.89
|
|
|
HC COMP BURN GARM TWO LEGS PREGNA
|
Facility
|
IP
|
$260.10
|
|
|
Service Code
|
HCPCS A6512
|
| Hospital Charge Code |
98300065
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$195.07 |
| Max. Negotiated Rate |
$260.10 |
| Rate for Payer: Aetna Commercial |
$234.09
|
| Rate for Payer: ASR ASR |
$252.30
|
| Rate for Payer: BCBS Trust/PPO |
$213.59
|
| Rate for Payer: BCN Commercial |
$213.59
|
| Rate for Payer: Cash Price |
$208.08
|
| Rate for Payer: Cofinity Commercial |
$244.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$208.08
|
| Rate for Payer: Healthscope Commercial |
$252.30
|
| Rate for Payer: Healthscope Whirlpool |
$260.10
|
| Rate for Payer: Mclaren Commercial |
$234.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$221.09
|
| Rate for Payer: Nomi Health Commercial |
$213.28
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$195.07
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$228.89
|
|
|
HC COMP BURN GARM VEST SLEEVED
|
Facility
|
IP
|
$260.10
|
|
|
Service Code
|
HCPCS A6509
|
| Hospital Charge Code |
98300066
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$195.07 |
| Max. Negotiated Rate |
$260.10 |
| Rate for Payer: Aetna Commercial |
$234.09
|
| Rate for Payer: ASR ASR |
$252.30
|
| Rate for Payer: BCBS Trust/PPO |
$213.59
|
| Rate for Payer: BCN Commercial |
$213.59
|
| Rate for Payer: Cash Price |
$208.08
|
| Rate for Payer: Cofinity Commercial |
$244.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$208.08
|
| Rate for Payer: Healthscope Commercial |
$252.30
|
| Rate for Payer: Healthscope Whirlpool |
$260.10
|
| Rate for Payer: Mclaren Commercial |
$234.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$221.09
|
| Rate for Payer: Nomi Health Commercial |
$213.28
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$195.07
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$228.89
|
|
|
HC COMP BURN GARM VEST SLEEVED
|
Facility
|
OP
|
$260.10
|
|
|
Service Code
|
HCPCS A6509
|
| Hospital Charge Code |
98300066
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$96.24 |
| Max. Negotiated Rate |
$260.10 |
| Rate for Payer: Aetna Commercial |
$234.09
|
| Rate for Payer: Aetna Medicare |
$96.24
|
| Rate for Payer: ASR ASR |
$252.30
|
| Rate for Payer: BCBS Complete |
$104.04
|
| Rate for Payer: BCBS Trust/PPO |
$214.45
|
| Rate for Payer: BCN Commercial |
$214.45
|
| Rate for Payer: Cash Price |
$208.08
|
| Rate for Payer: Cofinity Commercial |
$244.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$208.08
|
| Rate for Payer: Healthscope Commercial |
$252.30
|
| Rate for Payer: Healthscope Whirlpool |
$260.10
|
| Rate for Payer: Mclaren Commercial |
$234.09
|
| Rate for Payer: MI Amish Medical Board Commercial |
$208.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$221.09
|
| Rate for Payer: Nomi Health Commercial |
$213.28
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$195.07
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$227.90
|
| Rate for Payer: Priority Health Narrow Network |
$182.33
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$228.89
|
|
|
HC COMP BURN GARM VEST SLEEVELESS
|
Facility
|
OP
|
$137.33
|
|
|
Service Code
|
HCPCS A6509
|
| Hospital Charge Code |
98300067
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$50.81 |
| Max. Negotiated Rate |
$137.33 |
| Rate for Payer: Aetna Commercial |
$123.60
|
| Rate for Payer: Aetna Medicare |
$50.81
|
| Rate for Payer: ASR ASR |
$133.21
|
| Rate for Payer: BCBS Complete |
$54.93
|
| Rate for Payer: BCBS Trust/PPO |
$113.23
|
| Rate for Payer: BCN Commercial |
$113.23
|
| Rate for Payer: Cash Price |
$109.86
|
| Rate for Payer: Cofinity Commercial |
$129.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$109.86
|
| Rate for Payer: Healthscope Commercial |
$133.21
|
| Rate for Payer: Healthscope Whirlpool |
$137.33
|
| Rate for Payer: Mclaren Commercial |
$123.60
|
| Rate for Payer: MI Amish Medical Board Commercial |
$109.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$116.73
|
| Rate for Payer: Nomi Health Commercial |
$112.61
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$103.00
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$120.33
|
| Rate for Payer: Priority Health Narrow Network |
$96.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$120.85
|
|
|
HC COMP BURN GARM VEST SLEEVELESS
|
Facility
|
IP
|
$137.33
|
|
|
Service Code
|
HCPCS A6509
|
| Hospital Charge Code |
98300067
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$103.00 |
| Max. Negotiated Rate |
$137.33 |
| Rate for Payer: Aetna Commercial |
$123.60
|
| Rate for Payer: ASR ASR |
$133.21
|
| Rate for Payer: BCBS Trust/PPO |
$112.78
|
| Rate for Payer: BCN Commercial |
$112.78
|
| Rate for Payer: Cash Price |
$109.86
|
| Rate for Payer: Cofinity Commercial |
$129.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$109.86
|
| Rate for Payer: Healthscope Commercial |
$133.21
|
| Rate for Payer: Healthscope Whirlpool |
$137.33
|
| Rate for Payer: Mclaren Commercial |
$123.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$116.73
|
| Rate for Payer: Nomi Health Commercial |
$112.61
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$103.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$120.85
|
|
|
HC COMP BURN GARM ZIPPER
|
Facility
|
IP
|
$46.82
|
|
|
Service Code
|
HCPCS A9900
|
| Hospital Charge Code |
98300068
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$35.12 |
| Max. Negotiated Rate |
$46.82 |
| Rate for Payer: Aetna Commercial |
$42.14
|
| Rate for Payer: ASR ASR |
$45.42
|
| Rate for Payer: BCBS Trust/PPO |
$38.45
|
| Rate for Payer: BCN Commercial |
$38.45
|
| Rate for Payer: Cash Price |
$37.46
|
| Rate for Payer: Cofinity Commercial |
$44.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$37.46
|
| Rate for Payer: Healthscope Commercial |
$45.42
|
| Rate for Payer: Healthscope Whirlpool |
$46.82
|
| Rate for Payer: Mclaren Commercial |
$42.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$39.80
|
| Rate for Payer: Nomi Health Commercial |
$38.39
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$35.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$41.20
|
|
|
HC COMP BURN GARM ZIPPER
|
Facility
|
OP
|
$46.82
|
|
|
Service Code
|
HCPCS A9900
|
| Hospital Charge Code |
98300068
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$17.32 |
| Max. Negotiated Rate |
$46.82 |
| Rate for Payer: Aetna Commercial |
$42.14
|
| Rate for Payer: Aetna Medicare |
$17.32
|
| Rate for Payer: ASR ASR |
$45.42
|
| Rate for Payer: BCBS Complete |
$18.73
|
| Rate for Payer: BCBS Trust/PPO |
$38.60
|
| Rate for Payer: BCN Commercial |
$38.60
|
| Rate for Payer: Cash Price |
$37.46
|
| Rate for Payer: Cofinity Commercial |
$44.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$37.46
|
| Rate for Payer: Healthscope Commercial |
$45.42
|
| Rate for Payer: Healthscope Whirlpool |
$46.82
|
| Rate for Payer: Mclaren Commercial |
$42.14
|
| Rate for Payer: MI Amish Medical Board Commercial |
$37.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$39.80
|
| Rate for Payer: Nomi Health Commercial |
$38.39
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$35.12
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$41.02
|
| Rate for Payer: Priority Health Narrow Network |
$32.82
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$41.20
|
|
|
HC COMPLEMENT C 3
|
Facility
|
OP
|
$117.57
|
|
|
Service Code
|
CPT 86160
|
| Hospital Charge Code |
30200150
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$6.28 |
| Max. Negotiated Rate |
$117.57 |
| Rate for Payer: Aetna Commercial |
$105.81
|
| Rate for Payer: Aetna Medicare |
$12.00
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$15.00
|
| Rate for Payer: Amish Plain Church Group Commercial |
$15.00
|
| Rate for Payer: ASR ASR |
$114.04
|
| Rate for Payer: BCBS Complete |
$6.59
|
| Rate for Payer: BCBS MAPPO |
$12.00
|
| Rate for Payer: BCBS Trust/PPO |
$96.94
|
| Rate for Payer: BCN Commercial |
$96.94
|
| Rate for Payer: BCN Medicare Advantage |
$12.00
|
| Rate for Payer: Cash Price |
$94.06
|
| Rate for Payer: Cash Price |
$94.06
|
| Rate for Payer: Cofinity Commercial |
$110.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$94.06
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$12.00
|
| Rate for Payer: Healthscope Commercial |
$114.04
|
| Rate for Payer: Healthscope Whirlpool |
$117.57
|
| Rate for Payer: Humana Choice PPO Medicare |
$12.00
|
| Rate for Payer: Mclaren Commercial |
$105.81
|
| Rate for Payer: Mclaren Medicaid |
$12.00
|
| Rate for Payer: Mclaren Medicare |
$12.00
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$12.60
|
| Rate for Payer: Meridian Medicaid |
$6.59
|
| Rate for Payer: MI Amish Medical Board Commercial |
$13.80
|
| Rate for Payer: Molina Medicare/Medicaid |
$13.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$99.93
|
| Rate for Payer: Nomi Health Commercial |
$96.41
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$88.18
|
| Rate for Payer: PACE Medicare |
$11.40
|
| Rate for Payer: PACE SWMI |
$12.00
|
| Rate for Payer: PHP Commercial |
$13.20
|
| Rate for Payer: PHP Medicaid |
$6.43
|
| Rate for Payer: PHP Medicare Advantage |
$12.00
|
| Rate for Payer: Priority Health Choice Medicaid |
$6.28
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$43.60
|
| Rate for Payer: Priority Health Medicare |
$12.00
|
| Rate for Payer: Priority Health Narrow Network |
$34.88
|
| Rate for Payer: Railroad Medicare Medicare |
$12.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$103.46
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$12.00
|
| Rate for Payer: UHC Exchange |
$18.60
|
| Rate for Payer: UHC Medicaid |
$6.28
|
| Rate for Payer: UHCCP DNSP |
$12.00
|
| Rate for Payer: UHCCP Medicaid |
$6.28
|
| Rate for Payer: VA VA |
$12.00
|
|
|
HC COMPLEMENT C 3
|
Facility
|
IP
|
$117.57
|
|
|
Service Code
|
CPT 86160
|
| Hospital Charge Code |
30200150
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$88.18 |
| Max. Negotiated Rate |
$117.57 |
| Rate for Payer: Aetna Commercial |
$105.81
|
| Rate for Payer: ASR ASR |
$114.04
|
| Rate for Payer: BCBS Trust/PPO |
$96.55
|
| Rate for Payer: BCN Commercial |
$96.55
|
| Rate for Payer: Cash Price |
$94.06
|
| Rate for Payer: Cofinity Commercial |
$110.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$94.06
|
| Rate for Payer: Healthscope Commercial |
$114.04
|
| Rate for Payer: Healthscope Whirlpool |
$117.57
|
| Rate for Payer: Mclaren Commercial |
$105.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$99.93
|
| Rate for Payer: Nomi Health Commercial |
$96.41
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$88.18
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$103.46
|
|
|
HC COMPLEMENT C 4
|
Facility
|
OP
|
$117.57
|
|
|
Service Code
|
CPT 86160
|
| Hospital Charge Code |
30200151
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$6.28 |
| Max. Negotiated Rate |
$117.57 |
| Rate for Payer: Aetna Commercial |
$105.81
|
| Rate for Payer: Aetna Medicare |
$12.00
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$15.00
|
| Rate for Payer: Amish Plain Church Group Commercial |
$15.00
|
| Rate for Payer: ASR ASR |
$114.04
|
| Rate for Payer: BCBS Complete |
$6.59
|
| Rate for Payer: BCBS MAPPO |
$12.00
|
| Rate for Payer: BCBS Trust/PPO |
$96.94
|
| Rate for Payer: BCN Commercial |
$96.94
|
| Rate for Payer: BCN Medicare Advantage |
$12.00
|
| Rate for Payer: Cash Price |
$94.06
|
| Rate for Payer: Cash Price |
$94.06
|
| Rate for Payer: Cofinity Commercial |
$110.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$94.06
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$12.00
|
| Rate for Payer: Healthscope Commercial |
$114.04
|
| Rate for Payer: Healthscope Whirlpool |
$117.57
|
| Rate for Payer: Humana Choice PPO Medicare |
$12.00
|
| Rate for Payer: Mclaren Commercial |
$105.81
|
| Rate for Payer: Mclaren Medicaid |
$12.00
|
| Rate for Payer: Mclaren Medicare |
$12.00
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$12.60
|
| Rate for Payer: Meridian Medicaid |
$6.59
|
| Rate for Payer: MI Amish Medical Board Commercial |
$13.80
|
| Rate for Payer: Molina Medicare/Medicaid |
$13.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$99.93
|
| Rate for Payer: Nomi Health Commercial |
$96.41
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$88.18
|
| Rate for Payer: PACE Medicare |
$11.40
|
| Rate for Payer: PACE SWMI |
$12.00
|
| Rate for Payer: PHP Commercial |
$13.20
|
| Rate for Payer: PHP Medicaid |
$6.43
|
| Rate for Payer: PHP Medicare Advantage |
$12.00
|
| Rate for Payer: Priority Health Choice Medicaid |
$6.28
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$43.60
|
| Rate for Payer: Priority Health Medicare |
$12.00
|
| Rate for Payer: Priority Health Narrow Network |
$34.88
|
| Rate for Payer: Railroad Medicare Medicare |
$12.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$103.46
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$12.00
|
| Rate for Payer: UHC Exchange |
$18.60
|
| Rate for Payer: UHC Medicaid |
$6.28
|
| Rate for Payer: UHCCP DNSP |
$12.00
|
| Rate for Payer: UHCCP Medicaid |
$6.28
|
| Rate for Payer: VA VA |
$12.00
|
|
|
HC COMPLEMENT C 4
|
Facility
|
IP
|
$117.57
|
|
|
Service Code
|
CPT 86160
|
| Hospital Charge Code |
30200151
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$88.18 |
| Max. Negotiated Rate |
$117.57 |
| Rate for Payer: Aetna Commercial |
$105.81
|
| Rate for Payer: ASR ASR |
$114.04
|
| Rate for Payer: BCBS Trust/PPO |
$96.55
|
| Rate for Payer: BCN Commercial |
$96.55
|
| Rate for Payer: Cash Price |
$94.06
|
| Rate for Payer: Cofinity Commercial |
$110.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$94.06
|
| Rate for Payer: Healthscope Commercial |
$114.04
|
| Rate for Payer: Healthscope Whirlpool |
$117.57
|
| Rate for Payer: Mclaren Commercial |
$105.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$99.93
|
| Rate for Payer: Nomi Health Commercial |
$96.41
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$88.18
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$103.46
|
|
|
HC COMPLEMENT C 5
|
Facility
|
IP
|
$74.29
|
|
|
Service Code
|
CPT 86160
|
| Hospital Charge Code |
30200152
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$55.72 |
| Max. Negotiated Rate |
$74.29 |
| Rate for Payer: Aetna Commercial |
$66.86
|
| Rate for Payer: ASR ASR |
$72.06
|
| Rate for Payer: BCBS Trust/PPO |
$61.01
|
| Rate for Payer: BCN Commercial |
$61.01
|
| Rate for Payer: Cash Price |
$59.43
|
| Rate for Payer: Cofinity Commercial |
$69.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$59.43
|
| Rate for Payer: Healthscope Commercial |
$72.06
|
| Rate for Payer: Healthscope Whirlpool |
$74.29
|
| Rate for Payer: Mclaren Commercial |
$66.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$63.15
|
| Rate for Payer: Nomi Health Commercial |
$60.92
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$55.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$65.38
|
|
|
HC COMPLEMENT C 5
|
Facility
|
OP
|
$74.29
|
|
|
Service Code
|
CPT 86160
|
| Hospital Charge Code |
30200152
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$6.28 |
| Max. Negotiated Rate |
$74.29 |
| Rate for Payer: Aetna Commercial |
$66.86
|
| Rate for Payer: Aetna Medicare |
$12.00
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$15.00
|
| Rate for Payer: Amish Plain Church Group Commercial |
$15.00
|
| Rate for Payer: ASR ASR |
$72.06
|
| Rate for Payer: BCBS Complete |
$6.59
|
| Rate for Payer: BCBS MAPPO |
$12.00
|
| Rate for Payer: BCBS Trust/PPO |
$61.25
|
| Rate for Payer: BCN Commercial |
$61.25
|
| Rate for Payer: BCN Medicare Advantage |
$12.00
|
| Rate for Payer: Cash Price |
$59.43
|
| Rate for Payer: Cash Price |
$59.43
|
| Rate for Payer: Cofinity Commercial |
$69.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$59.43
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$12.00
|
| Rate for Payer: Healthscope Commercial |
$72.06
|
| Rate for Payer: Healthscope Whirlpool |
$74.29
|
| Rate for Payer: Humana Choice PPO Medicare |
$12.00
|
| Rate for Payer: Mclaren Commercial |
$66.86
|
| Rate for Payer: Mclaren Medicaid |
$12.00
|
| Rate for Payer: Mclaren Medicare |
$12.00
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$12.60
|
| Rate for Payer: Meridian Medicaid |
$6.59
|
| Rate for Payer: MI Amish Medical Board Commercial |
$13.80
|
| Rate for Payer: Molina Medicare/Medicaid |
$13.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$63.15
|
| Rate for Payer: Nomi Health Commercial |
$60.92
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$55.72
|
| Rate for Payer: PACE Medicare |
$11.40
|
| Rate for Payer: PACE SWMI |
$12.00
|
| Rate for Payer: PHP Commercial |
$13.20
|
| Rate for Payer: PHP Medicaid |
$6.43
|
| Rate for Payer: PHP Medicare Advantage |
$12.00
|
| Rate for Payer: Priority Health Choice Medicaid |
$6.28
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$43.60
|
| Rate for Payer: Priority Health Medicare |
$12.00
|
| Rate for Payer: Priority Health Narrow Network |
$34.88
|
| Rate for Payer: Railroad Medicare Medicare |
$12.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$65.38
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$12.00
|
| Rate for Payer: UHC Exchange |
$18.60
|
| Rate for Payer: UHC Medicaid |
$6.28
|
| Rate for Payer: UHCCP DNSP |
$12.00
|
| Rate for Payer: UHCCP Medicaid |
$6.28
|
| Rate for Payer: VA VA |
$12.00
|
|
|
HC COMPLEMENT CH50 TOTAL
|
Facility
|
IP
|
$40.33
|
|
|
Service Code
|
CPT 86162
|
| Hospital Charge Code |
30200154
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$30.25 |
| Max. Negotiated Rate |
$40.33 |
| Rate for Payer: Aetna Commercial |
$36.30
|
| Rate for Payer: ASR ASR |
$39.12
|
| Rate for Payer: BCBS Trust/PPO |
$33.12
|
| Rate for Payer: BCN Commercial |
$33.12
|
| Rate for Payer: Cash Price |
$32.26
|
| Rate for Payer: Cofinity Commercial |
$37.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$32.26
|
| Rate for Payer: Healthscope Commercial |
$39.12
|
| Rate for Payer: Healthscope Whirlpool |
$40.33
|
| Rate for Payer: Mclaren Commercial |
$36.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$34.28
|
| Rate for Payer: Nomi Health Commercial |
$33.07
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$30.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$35.49
|
|
|
HC COMPLEMENT CH50 TOTAL
|
Facility
|
OP
|
$40.33
|
|
|
Service Code
|
CPT 86162
|
| Hospital Charge Code |
30200154
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$10.63 |
| Max. Negotiated Rate |
$69.02 |
| Rate for Payer: Aetna Commercial |
$36.30
|
| Rate for Payer: Aetna Medicare |
$20.32
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$25.40
|
| Rate for Payer: Amish Plain Church Group Commercial |
$25.40
|
| Rate for Payer: ASR ASR |
$39.12
|
| Rate for Payer: BCBS Complete |
$11.16
|
| Rate for Payer: BCBS MAPPO |
$20.32
|
| Rate for Payer: BCBS Trust/PPO |
$33.25
|
| Rate for Payer: BCN Commercial |
$33.25
|
| Rate for Payer: BCN Medicare Advantage |
$20.32
|
| Rate for Payer: Cash Price |
$32.26
|
| Rate for Payer: Cash Price |
$32.26
|
| Rate for Payer: Cofinity Commercial |
$37.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$32.26
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$20.32
|
| Rate for Payer: Healthscope Commercial |
$39.12
|
| Rate for Payer: Healthscope Whirlpool |
$40.33
|
| Rate for Payer: Humana Choice PPO Medicare |
$20.32
|
| Rate for Payer: Mclaren Commercial |
$36.30
|
| Rate for Payer: Mclaren Medicaid |
$20.32
|
| Rate for Payer: Mclaren Medicare |
$20.32
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$21.34
|
| Rate for Payer: Meridian Medicaid |
$11.16
|
| Rate for Payer: MI Amish Medical Board Commercial |
$23.37
|
| Rate for Payer: Molina Medicare/Medicaid |
$22.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$34.28
|
| Rate for Payer: Nomi Health Commercial |
$33.07
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$30.25
|
| Rate for Payer: PACE Medicare |
$19.30
|
| Rate for Payer: PACE SWMI |
$20.32
|
| Rate for Payer: PHP Commercial |
$22.35
|
| Rate for Payer: PHP Medicaid |
$10.89
|
| Rate for Payer: PHP Medicare Advantage |
$20.32
|
| Rate for Payer: Priority Health Choice Medicaid |
$10.63
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$69.02
|
| Rate for Payer: Priority Health Medicare |
$20.32
|
| Rate for Payer: Priority Health Narrow Network |
$55.21
|
| Rate for Payer: Railroad Medicare Medicare |
$20.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$35.49
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$20.32
|
| Rate for Payer: UHC Exchange |
$31.50
|
| Rate for Payer: UHC Medicaid |
$10.63
|
| Rate for Payer: UHCCP DNSP |
$20.32
|
| Rate for Payer: UHCCP Medicaid |
$10.63
|
| Rate for Payer: VA VA |
$20.32
|
|
|
HC COMPLEX CYSTOMETROGRAM
|
Facility
|
OP
|
$405.22
|
|
|
Service Code
|
CPT 51726
|
| Hospital Charge Code |
76100190
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$130.20 |
| Max. Negotiated Rate |
$405.22 |
| Rate for Payer: Aetna Commercial |
$364.70
|
| Rate for Payer: Aetna Medicare |
$248.95
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$311.19
|
| Rate for Payer: Amish Plain Church Group Commercial |
$311.19
|
| Rate for Payer: ASR ASR |
$393.06
|
| Rate for Payer: BCBS Complete |
$136.72
|
| Rate for Payer: BCBS MAPPO |
$248.95
|
| Rate for Payer: BCBS Trust/PPO |
$334.10
|
| Rate for Payer: BCN Commercial |
$334.10
|
| Rate for Payer: BCN Medicare Advantage |
$248.95
|
| Rate for Payer: Cash Price |
$324.18
|
| Rate for Payer: Cash Price |
$324.18
|
| Rate for Payer: Cofinity Commercial |
$380.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$324.18
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$248.95
|
| Rate for Payer: Healthscope Commercial |
$393.06
|
| Rate for Payer: Healthscope Whirlpool |
$405.22
|
| Rate for Payer: Humana Choice PPO Medicare |
$248.95
|
| Rate for Payer: Mclaren Commercial |
$364.70
|
| Rate for Payer: Mclaren Medicaid |
$248.95
|
| Rate for Payer: Mclaren Medicare |
$248.95
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$261.40
|
| Rate for Payer: Meridian Medicaid |
$136.72
|
| Rate for Payer: MI Amish Medical Board Commercial |
$286.29
|
| Rate for Payer: Molina Medicare/Medicaid |
$273.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$344.44
|
| Rate for Payer: Nomi Health Commercial |
$332.28
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$303.92
|
| Rate for Payer: PACE Medicare |
$236.50
|
| Rate for Payer: PACE SWMI |
$248.95
|
| Rate for Payer: PHP Commercial |
$273.85
|
| Rate for Payer: PHP Medicaid |
$133.44
|
| Rate for Payer: PHP Medicare Advantage |
$248.95
|
| Rate for Payer: Priority Health Choice Medicaid |
$130.20
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$355.05
|
| Rate for Payer: Priority Health Medicare |
$248.95
|
| Rate for Payer: Priority Health Narrow Network |
$284.06
|
| Rate for Payer: Railroad Medicare Medicare |
$248.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$356.59
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$248.95
|
| Rate for Payer: UHC Exchange |
$385.87
|
| Rate for Payer: UHC Medicaid |
$130.20
|
| Rate for Payer: UHCCP DNSP |
$248.95
|
| Rate for Payer: UHCCP Medicaid |
$130.20
|
| Rate for Payer: VA VA |
$248.95
|
|
