|
HC COMP BURN GARM SUEDE/LEATHER G
|
Facility
|
OP
|
$45.90
|
|
|
Service Code
|
HCPCS A9900
|
| Hospital Charge Code |
98300058
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$18.36 |
| Max. Negotiated Rate |
$45.90 |
| Rate for Payer: Aetna Commercial |
$41.31
|
| Rate for Payer: Aetna Medicare |
$22.95
|
| Rate for Payer: ASR ASR |
$44.52
|
| Rate for Payer: ASR Commercial |
$44.52
|
| Rate for Payer: BCBS Complete |
$18.36
|
| Rate for Payer: BCBS Trust/PPO |
$37.59
|
| Rate for Payer: BCN Commercial |
$35.59
|
| Rate for Payer: Cash Price |
$36.72
|
| Rate for Payer: Cofinity Commercial |
$43.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$36.72
|
| Rate for Payer: Healthscope Commercial |
$45.90
|
| Rate for Payer: Healthscope Whirlpool |
$44.52
|
| Rate for Payer: Mclaren Commercial |
$41.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$39.02
|
| Rate for Payer: Nomi Health Commercial |
$37.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$29.84
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$40.22
|
| Rate for Payer: Priority Health Narrow Network |
$32.18
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$40.39
|
|
|
HC COMP BURN GARM SUEDE/LEATHER G
|
Facility
|
IP
|
$45.90
|
|
|
Service Code
|
HCPCS A9900
|
| Hospital Charge Code |
98300058
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$29.84 |
| Max. Negotiated Rate |
$45.90 |
| Rate for Payer: Aetna Commercial |
$41.31
|
| Rate for Payer: ASR ASR |
$44.52
|
| Rate for Payer: ASR Commercial |
$44.52
|
| Rate for Payer: BCBS Trust/PPO |
$37.40
|
| Rate for Payer: BCN Commercial |
$35.59
|
| Rate for Payer: Cash Price |
$36.72
|
| Rate for Payer: Cofinity Commercial |
$43.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$36.72
|
| Rate for Payer: Healthscope Commercial |
$45.90
|
| Rate for Payer: Healthscope Whirlpool |
$44.52
|
| Rate for Payer: Mclaren Commercial |
$41.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$39.02
|
| Rate for Payer: Nomi Health Commercial |
$37.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$29.84
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$40.39
|
|
|
HC COMP BURN GARM SUIT SLVD ABV K
|
Facility
|
OP
|
$387.60
|
|
|
Service Code
|
HCPCS A6512
|
| Hospital Charge Code |
98300059
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$155.04 |
| Max. Negotiated Rate |
$387.60 |
| Rate for Payer: Aetna Commercial |
$348.84
|
| Rate for Payer: Aetna Medicare |
$193.80
|
| Rate for Payer: ASR ASR |
$375.97
|
| Rate for Payer: ASR Commercial |
$375.97
|
| Rate for Payer: BCBS Complete |
$155.04
|
| Rate for Payer: BCBS Trust/PPO |
$317.41
|
| Rate for Payer: BCN Commercial |
$300.51
|
| Rate for Payer: Cash Price |
$310.08
|
| Rate for Payer: Cofinity Commercial |
$364.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$310.08
|
| Rate for Payer: Healthscope Commercial |
$387.60
|
| Rate for Payer: Healthscope Whirlpool |
$375.97
|
| Rate for Payer: Mclaren Commercial |
$348.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$329.46
|
| Rate for Payer: Nomi Health Commercial |
$317.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$251.94
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$339.62
|
| Rate for Payer: Priority Health Narrow Network |
$271.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$341.09
|
|
|
HC COMP BURN GARM SUIT SLVD ABV K
|
Facility
|
IP
|
$387.60
|
|
|
Service Code
|
HCPCS A6512
|
| Hospital Charge Code |
98300059
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$251.94 |
| Max. Negotiated Rate |
$387.60 |
| Rate for Payer: Aetna Commercial |
$348.84
|
| Rate for Payer: ASR ASR |
$375.97
|
| Rate for Payer: ASR Commercial |
$375.97
|
| Rate for Payer: BCBS Trust/PPO |
$315.86
|
| Rate for Payer: BCN Commercial |
$300.51
|
| Rate for Payer: Cash Price |
$310.08
|
| Rate for Payer: Cofinity Commercial |
$364.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$310.08
|
| Rate for Payer: Healthscope Commercial |
$387.60
|
| Rate for Payer: Healthscope Whirlpool |
$375.97
|
| Rate for Payer: Mclaren Commercial |
$348.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$329.46
|
| Rate for Payer: Nomi Health Commercial |
$317.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$251.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$341.09
|
|
|
HC COMP BURN GARM SUIT SLVD TWO LEGS
|
Facility
|
IP
|
$491.64
|
|
|
Service Code
|
HCPCS A6501
|
| Hospital Charge Code |
98300060
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$319.57 |
| Max. Negotiated Rate |
$491.64 |
| Rate for Payer: Aetna Commercial |
$442.48
|
| Rate for Payer: ASR ASR |
$476.89
|
| Rate for Payer: ASR Commercial |
$476.89
|
| Rate for Payer: BCBS Trust/PPO |
$400.64
|
| Rate for Payer: BCN Commercial |
$381.17
|
| Rate for Payer: Cash Price |
$393.31
|
| Rate for Payer: Cofinity Commercial |
$462.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$393.31
|
| Rate for Payer: Healthscope Commercial |
$491.64
|
| Rate for Payer: Healthscope Whirlpool |
$476.89
|
| Rate for Payer: Mclaren Commercial |
$442.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$417.89
|
| Rate for Payer: Nomi Health Commercial |
$403.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$319.57
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$432.64
|
|
|
HC COMP BURN GARM SUIT SLVD TWO LEGS
|
Facility
|
OP
|
$491.64
|
|
|
Service Code
|
HCPCS A6501
|
| Hospital Charge Code |
98300060
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$196.66 |
| Max. Negotiated Rate |
$491.64 |
| Rate for Payer: Aetna Commercial |
$442.48
|
| Rate for Payer: Aetna Medicare |
$245.82
|
| Rate for Payer: ASR ASR |
$476.89
|
| Rate for Payer: ASR Commercial |
$476.89
|
| Rate for Payer: BCBS Complete |
$196.66
|
| Rate for Payer: BCBS Trust/PPO |
$402.60
|
| Rate for Payer: BCN Commercial |
$381.17
|
| Rate for Payer: Cash Price |
$393.31
|
| Rate for Payer: Cofinity Commercial |
$462.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$393.31
|
| Rate for Payer: Healthscope Commercial |
$491.64
|
| Rate for Payer: Healthscope Whirlpool |
$476.89
|
| Rate for Payer: Mclaren Commercial |
$442.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$417.89
|
| Rate for Payer: Nomi Health Commercial |
$403.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$319.57
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$430.77
|
| Rate for Payer: Priority Health Narrow Network |
$344.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$432.64
|
|
|
HC COMP BURN GARM SUIT SLVLS ABV
|
Facility
|
IP
|
$320.28
|
|
|
Service Code
|
HCPCS A6512
|
| Hospital Charge Code |
98300061
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$208.18 |
| Max. Negotiated Rate |
$320.28 |
| Rate for Payer: Aetna Commercial |
$288.25
|
| Rate for Payer: ASR ASR |
$310.67
|
| Rate for Payer: ASR Commercial |
$310.67
|
| Rate for Payer: BCBS Trust/PPO |
$261.00
|
| Rate for Payer: BCN Commercial |
$248.31
|
| Rate for Payer: Cash Price |
$256.22
|
| Rate for Payer: Cofinity Commercial |
$301.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$256.22
|
| Rate for Payer: Healthscope Commercial |
$320.28
|
| Rate for Payer: Healthscope Whirlpool |
$310.67
|
| Rate for Payer: Mclaren Commercial |
$288.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$272.24
|
| Rate for Payer: Nomi Health Commercial |
$262.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$208.18
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$281.85
|
|
|
HC COMP BURN GARM SUIT SLVLS ABV
|
Facility
|
OP
|
$320.28
|
|
|
Service Code
|
HCPCS A6512
|
| Hospital Charge Code |
98300061
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$128.11 |
| Max. Negotiated Rate |
$320.28 |
| Rate for Payer: Aetna Commercial |
$288.25
|
| Rate for Payer: Aetna Medicare |
$160.14
|
| Rate for Payer: ASR ASR |
$310.67
|
| Rate for Payer: ASR Commercial |
$310.67
|
| Rate for Payer: BCBS Complete |
$128.11
|
| Rate for Payer: BCBS Trust/PPO |
$262.28
|
| Rate for Payer: BCN Commercial |
$248.31
|
| Rate for Payer: Cash Price |
$256.22
|
| Rate for Payer: Cofinity Commercial |
$301.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$256.22
|
| Rate for Payer: Healthscope Commercial |
$320.28
|
| Rate for Payer: Healthscope Whirlpool |
$310.67
|
| Rate for Payer: Mclaren Commercial |
$288.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$272.24
|
| Rate for Payer: Nomi Health Commercial |
$262.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$208.18
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$280.63
|
| Rate for Payer: Priority Health Narrow Network |
$224.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$281.85
|
|
|
HC COMP BURN GARM SUIT SLVLS-TWO LEGS
|
Facility
|
IP
|
$375.36
|
|
|
Service Code
|
HCPCS A6512
|
| Hospital Charge Code |
98300062
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$243.98 |
| Max. Negotiated Rate |
$375.36 |
| Rate for Payer: Aetna Commercial |
$337.82
|
| Rate for Payer: ASR ASR |
$364.10
|
| Rate for Payer: ASR Commercial |
$364.10
|
| Rate for Payer: BCBS Trust/PPO |
$305.88
|
| Rate for Payer: BCN Commercial |
$291.02
|
| Rate for Payer: Cash Price |
$300.29
|
| Rate for Payer: Cofinity Commercial |
$352.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$300.29
|
| Rate for Payer: Healthscope Commercial |
$375.36
|
| Rate for Payer: Healthscope Whirlpool |
$364.10
|
| Rate for Payer: Mclaren Commercial |
$337.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$319.06
|
| Rate for Payer: Nomi Health Commercial |
$307.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$243.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$330.32
|
|
|
HC COMP BURN GARM SUIT SLVLS-TWO LEGS
|
Facility
|
OP
|
$375.36
|
|
|
Service Code
|
HCPCS A6512
|
| Hospital Charge Code |
98300062
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$150.14 |
| Max. Negotiated Rate |
$375.36 |
| Rate for Payer: Aetna Commercial |
$337.82
|
| Rate for Payer: Aetna Medicare |
$187.68
|
| Rate for Payer: ASR ASR |
$364.10
|
| Rate for Payer: ASR Commercial |
$364.10
|
| Rate for Payer: BCBS Complete |
$150.14
|
| Rate for Payer: BCBS Trust/PPO |
$307.38
|
| Rate for Payer: BCN Commercial |
$291.02
|
| Rate for Payer: Cash Price |
$300.29
|
| Rate for Payer: Cofinity Commercial |
$352.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$300.29
|
| Rate for Payer: Healthscope Commercial |
$375.36
|
| Rate for Payer: Healthscope Whirlpool |
$364.10
|
| Rate for Payer: Mclaren Commercial |
$337.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$319.06
|
| Rate for Payer: Nomi Health Commercial |
$307.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$243.98
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$328.89
|
| Rate for Payer: Priority Health Narrow Network |
$263.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$330.32
|
|
|
HC COMP BURN GARM SUSPENDERS ATTA
|
Facility
|
OP
|
$45.90
|
|
|
Service Code
|
HCPCS A9900
|
| Hospital Charge Code |
98300063
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$18.36 |
| Max. Negotiated Rate |
$45.90 |
| Rate for Payer: Aetna Commercial |
$41.31
|
| Rate for Payer: Aetna Medicare |
$22.95
|
| Rate for Payer: ASR ASR |
$44.52
|
| Rate for Payer: ASR Commercial |
$44.52
|
| Rate for Payer: BCBS Complete |
$18.36
|
| Rate for Payer: BCBS Trust/PPO |
$37.59
|
| Rate for Payer: BCN Commercial |
$35.59
|
| Rate for Payer: Cash Price |
$36.72
|
| Rate for Payer: Cofinity Commercial |
$43.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$36.72
|
| Rate for Payer: Healthscope Commercial |
$45.90
|
| Rate for Payer: Healthscope Whirlpool |
$44.52
|
| Rate for Payer: Mclaren Commercial |
$41.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$39.02
|
| Rate for Payer: Nomi Health Commercial |
$37.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$29.84
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$40.22
|
| Rate for Payer: Priority Health Narrow Network |
$32.18
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$40.39
|
|
|
HC COMP BURN GARM SUSPENDERS ATTA
|
Facility
|
IP
|
$45.90
|
|
|
Service Code
|
HCPCS A9900
|
| Hospital Charge Code |
98300063
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$29.84 |
| Max. Negotiated Rate |
$45.90 |
| Rate for Payer: Aetna Commercial |
$41.31
|
| Rate for Payer: ASR ASR |
$44.52
|
| Rate for Payer: ASR Commercial |
$44.52
|
| Rate for Payer: BCBS Trust/PPO |
$37.40
|
| Rate for Payer: BCN Commercial |
$35.59
|
| Rate for Payer: Cash Price |
$36.72
|
| Rate for Payer: Cofinity Commercial |
$43.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$36.72
|
| Rate for Payer: Healthscope Commercial |
$45.90
|
| Rate for Payer: Healthscope Whirlpool |
$44.52
|
| Rate for Payer: Mclaren Commercial |
$41.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$39.02
|
| Rate for Payer: Nomi Health Commercial |
$37.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$29.84
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$40.39
|
|
|
HC COMP BURN GARM SUSPENDERS REMO
|
Facility
|
OP
|
$12.24
|
|
|
Service Code
|
HCPCS A9900
|
| Hospital Charge Code |
98300064
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$4.90 |
| Max. Negotiated Rate |
$12.24 |
| Rate for Payer: Aetna Commercial |
$11.02
|
| Rate for Payer: Aetna Medicare |
$6.12
|
| Rate for Payer: ASR ASR |
$11.87
|
| Rate for Payer: ASR Commercial |
$11.87
|
| Rate for Payer: BCBS Complete |
$4.90
|
| Rate for Payer: BCBS Trust/PPO |
$10.02
|
| Rate for Payer: BCN Commercial |
$9.49
|
| Rate for Payer: Cash Price |
$9.79
|
| Rate for Payer: Cofinity Commercial |
$11.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.79
|
| Rate for Payer: Healthscope Commercial |
$12.24
|
| Rate for Payer: Healthscope Whirlpool |
$11.87
|
| Rate for Payer: Mclaren Commercial |
$11.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.40
|
| Rate for Payer: Nomi Health Commercial |
$10.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.96
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$10.72
|
| Rate for Payer: Priority Health Narrow Network |
$8.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$10.77
|
|
|
HC COMP BURN GARM SUSPENDERS REMO
|
Facility
|
IP
|
$12.24
|
|
|
Service Code
|
HCPCS A9900
|
| Hospital Charge Code |
98300064
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$7.96 |
| Max. Negotiated Rate |
$12.24 |
| Rate for Payer: Aetna Commercial |
$11.02
|
| Rate for Payer: ASR ASR |
$11.87
|
| Rate for Payer: ASR Commercial |
$11.87
|
| Rate for Payer: BCBS Trust/PPO |
$9.97
|
| Rate for Payer: BCN Commercial |
$9.49
|
| Rate for Payer: Cash Price |
$9.79
|
| Rate for Payer: Cofinity Commercial |
$11.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.79
|
| Rate for Payer: Healthscope Commercial |
$12.24
|
| Rate for Payer: Healthscope Whirlpool |
$11.87
|
| Rate for Payer: Mclaren Commercial |
$11.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.40
|
| Rate for Payer: Nomi Health Commercial |
$10.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$10.77
|
|
|
HC COMP BURN GARM TWO LEGS PREGNA
|
Facility
|
OP
|
$255.00
|
|
|
Service Code
|
HCPCS A6512
|
| Hospital Charge Code |
98300065
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$102.00 |
| Max. Negotiated Rate |
$255.00 |
| Rate for Payer: Aetna Commercial |
$229.50
|
| Rate for Payer: Aetna Medicare |
$127.50
|
| Rate for Payer: ASR ASR |
$247.35
|
| Rate for Payer: ASR Commercial |
$247.35
|
| Rate for Payer: BCBS Complete |
$102.00
|
| Rate for Payer: BCBS Trust/PPO |
$208.82
|
| Rate for Payer: BCN Commercial |
$197.70
|
| Rate for Payer: Cash Price |
$204.00
|
| Rate for Payer: Cofinity Commercial |
$239.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$204.00
|
| Rate for Payer: Healthscope Commercial |
$255.00
|
| Rate for Payer: Healthscope Whirlpool |
$247.35
|
| Rate for Payer: Mclaren Commercial |
$229.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$216.75
|
| Rate for Payer: Nomi Health Commercial |
$209.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$165.75
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$223.43
|
| Rate for Payer: Priority Health Narrow Network |
$178.76
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$224.40
|
|
|
HC COMP BURN GARM TWO LEGS PREGNA
|
Facility
|
IP
|
$255.00
|
|
|
Service Code
|
HCPCS A6512
|
| Hospital Charge Code |
98300065
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$165.75 |
| Max. Negotiated Rate |
$255.00 |
| Rate for Payer: Aetna Commercial |
$229.50
|
| Rate for Payer: ASR ASR |
$247.35
|
| Rate for Payer: ASR Commercial |
$247.35
|
| Rate for Payer: BCBS Trust/PPO |
$207.80
|
| Rate for Payer: BCN Commercial |
$197.70
|
| Rate for Payer: Cash Price |
$204.00
|
| Rate for Payer: Cofinity Commercial |
$239.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$204.00
|
| Rate for Payer: Healthscope Commercial |
$255.00
|
| Rate for Payer: Healthscope Whirlpool |
$247.35
|
| Rate for Payer: Mclaren Commercial |
$229.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$216.75
|
| Rate for Payer: Nomi Health Commercial |
$209.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$165.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$224.40
|
|
|
HC COMP BURN GARM VEST SLEEVED
|
Facility
|
IP
|
$255.00
|
|
|
Service Code
|
HCPCS A6509
|
| Hospital Charge Code |
98300066
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$165.75 |
| Max. Negotiated Rate |
$255.00 |
| Rate for Payer: Aetna Commercial |
$229.50
|
| Rate for Payer: ASR ASR |
$247.35
|
| Rate for Payer: ASR Commercial |
$247.35
|
| Rate for Payer: BCBS Trust/PPO |
$207.80
|
| Rate for Payer: BCN Commercial |
$197.70
|
| Rate for Payer: Cash Price |
$204.00
|
| Rate for Payer: Cofinity Commercial |
$239.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$204.00
|
| Rate for Payer: Healthscope Commercial |
$255.00
|
| Rate for Payer: Healthscope Whirlpool |
$247.35
|
| Rate for Payer: Mclaren Commercial |
$229.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$216.75
|
| Rate for Payer: Nomi Health Commercial |
$209.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$165.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$224.40
|
|
|
HC COMP BURN GARM VEST SLEEVED
|
Facility
|
OP
|
$255.00
|
|
|
Service Code
|
HCPCS A6509
|
| Hospital Charge Code |
98300066
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$102.00 |
| Max. Negotiated Rate |
$255.00 |
| Rate for Payer: Aetna Commercial |
$229.50
|
| Rate for Payer: Aetna Medicare |
$127.50
|
| Rate for Payer: ASR ASR |
$247.35
|
| Rate for Payer: ASR Commercial |
$247.35
|
| Rate for Payer: BCBS Complete |
$102.00
|
| Rate for Payer: BCBS Trust/PPO |
$208.82
|
| Rate for Payer: BCN Commercial |
$197.70
|
| Rate for Payer: Cash Price |
$204.00
|
| Rate for Payer: Cofinity Commercial |
$239.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$204.00
|
| Rate for Payer: Healthscope Commercial |
$255.00
|
| Rate for Payer: Healthscope Whirlpool |
$247.35
|
| Rate for Payer: Mclaren Commercial |
$229.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$216.75
|
| Rate for Payer: Nomi Health Commercial |
$209.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$165.75
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$223.43
|
| Rate for Payer: Priority Health Narrow Network |
$178.76
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$224.40
|
|
|
HC COMP BURN GARM VEST SLEEVELESS
|
Facility
|
OP
|
$134.64
|
|
|
Service Code
|
HCPCS A6509
|
| Hospital Charge Code |
98300067
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$53.86 |
| Max. Negotiated Rate |
$134.64 |
| Rate for Payer: Aetna Commercial |
$121.18
|
| Rate for Payer: Aetna Medicare |
$67.32
|
| Rate for Payer: ASR ASR |
$130.60
|
| Rate for Payer: ASR Commercial |
$130.60
|
| Rate for Payer: BCBS Complete |
$53.86
|
| Rate for Payer: BCBS Trust/PPO |
$110.26
|
| Rate for Payer: BCN Commercial |
$104.39
|
| Rate for Payer: Cash Price |
$107.71
|
| Rate for Payer: Cofinity Commercial |
$126.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$107.71
|
| Rate for Payer: Healthscope Commercial |
$134.64
|
| Rate for Payer: Healthscope Whirlpool |
$130.60
|
| Rate for Payer: Mclaren Commercial |
$121.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$114.44
|
| Rate for Payer: Nomi Health Commercial |
$110.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$87.52
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$117.97
|
| Rate for Payer: Priority Health Narrow Network |
$94.38
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$118.48
|
|
|
HC COMP BURN GARM VEST SLEEVELESS
|
Facility
|
IP
|
$134.64
|
|
|
Service Code
|
HCPCS A6509
|
| Hospital Charge Code |
98300067
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$87.52 |
| Max. Negotiated Rate |
$134.64 |
| Rate for Payer: Aetna Commercial |
$121.18
|
| Rate for Payer: ASR ASR |
$130.60
|
| Rate for Payer: ASR Commercial |
$130.60
|
| Rate for Payer: BCBS Trust/PPO |
$109.72
|
| Rate for Payer: BCN Commercial |
$104.39
|
| Rate for Payer: Cash Price |
$107.71
|
| Rate for Payer: Cofinity Commercial |
$126.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$107.71
|
| Rate for Payer: Healthscope Commercial |
$134.64
|
| Rate for Payer: Healthscope Whirlpool |
$130.60
|
| Rate for Payer: Mclaren Commercial |
$121.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$114.44
|
| Rate for Payer: Nomi Health Commercial |
$110.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$87.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$118.48
|
|
|
HC COMP BURN GARM ZIPPER
|
Facility
|
OP
|
$45.90
|
|
|
Service Code
|
HCPCS A9900
|
| Hospital Charge Code |
98300068
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$18.36 |
| Max. Negotiated Rate |
$45.90 |
| Rate for Payer: Aetna Commercial |
$41.31
|
| Rate for Payer: Aetna Medicare |
$22.95
|
| Rate for Payer: ASR ASR |
$44.52
|
| Rate for Payer: ASR Commercial |
$44.52
|
| Rate for Payer: BCBS Complete |
$18.36
|
| Rate for Payer: BCBS Trust/PPO |
$37.59
|
| Rate for Payer: BCN Commercial |
$35.59
|
| Rate for Payer: Cash Price |
$36.72
|
| Rate for Payer: Cofinity Commercial |
$43.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$36.72
|
| Rate for Payer: Healthscope Commercial |
$45.90
|
| Rate for Payer: Healthscope Whirlpool |
$44.52
|
| Rate for Payer: Mclaren Commercial |
$41.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$39.02
|
| Rate for Payer: Nomi Health Commercial |
$37.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$29.84
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$40.22
|
| Rate for Payer: Priority Health Narrow Network |
$32.18
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$40.39
|
|
|
HC COMP BURN GARM ZIPPER
|
Facility
|
IP
|
$45.90
|
|
|
Service Code
|
HCPCS A9900
|
| Hospital Charge Code |
98300068
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$29.84 |
| Max. Negotiated Rate |
$45.90 |
| Rate for Payer: Aetna Commercial |
$41.31
|
| Rate for Payer: ASR ASR |
$44.52
|
| Rate for Payer: ASR Commercial |
$44.52
|
| Rate for Payer: BCBS Trust/PPO |
$37.40
|
| Rate for Payer: BCN Commercial |
$35.59
|
| Rate for Payer: Cash Price |
$36.72
|
| Rate for Payer: Cofinity Commercial |
$43.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$36.72
|
| Rate for Payer: Healthscope Commercial |
$45.90
|
| Rate for Payer: Healthscope Whirlpool |
$44.52
|
| Rate for Payer: Mclaren Commercial |
$41.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$39.02
|
| Rate for Payer: Nomi Health Commercial |
$37.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$29.84
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$40.39
|
|
|
HC COMPLEMENT C 3
|
Facility
|
OP
|
$115.26
|
|
|
Service Code
|
CPT 86160
|
| Hospital Charge Code |
30200150
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$6.43 |
| Max. Negotiated Rate |
$115.26 |
| Rate for Payer: Aetna Commercial |
$103.73
|
| 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 |
$111.80
|
| Rate for Payer: ASR Commercial |
$111.80
|
| Rate for Payer: BCBS Complete |
$6.75
|
| Rate for Payer: BCBS MAPPO |
$12.00
|
| Rate for Payer: BCBS Trust/PPO |
$94.39
|
| Rate for Payer: BCN Commercial |
$89.36
|
| Rate for Payer: BCN Medicare Advantage |
$12.00
|
| Rate for Payer: Cash Price |
$92.21
|
| Rate for Payer: Cash Price |
$92.21
|
| Rate for Payer: Cofinity Commercial |
$108.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$92.21
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$12.00
|
| Rate for Payer: Healthscope Commercial |
$115.26
|
| Rate for Payer: Healthscope Whirlpool |
$111.80
|
| Rate for Payer: Humana Choice PPO Medicare |
$12.00
|
| Rate for Payer: Mclaren Commercial |
$103.73
|
| Rate for Payer: Mclaren Medicaid |
$6.43
|
| 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 |
$6.75
|
| Rate for Payer: MI Amish Medical Board Commercial |
$13.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$97.97
|
| Rate for Payer: Nomi Health Commercial |
$94.51
|
| 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 |
$6.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$74.92
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$39.54
|
| Rate for Payer: Priority Health Medicare |
$12.00
|
| Rate for Payer: Priority Health Narrow Network |
$31.63
|
| Rate for Payer: Railroad Medicare Medicare |
$12.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$101.43
|
| Rate for Payer: UHC Dual Complete DSNP |
$12.00
|
| Rate for Payer: UHC Exchange |
$18.60
|
| Rate for Payer: UHC Medicare Advantage |
$12.00
|
| Rate for Payer: UHCCP DNSP |
$12.00
|
| Rate for Payer: UHCCP Medicaid |
$6.43
|
| Rate for Payer: VA VA |
$12.00
|
|
|
HC COMPLEMENT C 3
|
Facility
|
IP
|
$115.26
|
|
|
Service Code
|
CPT 86160
|
| Hospital Charge Code |
30200150
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$74.92 |
| Max. Negotiated Rate |
$115.26 |
| Rate for Payer: Aetna Commercial |
$103.73
|
| Rate for Payer: ASR ASR |
$111.80
|
| Rate for Payer: ASR Commercial |
$111.80
|
| Rate for Payer: BCBS Trust/PPO |
$93.93
|
| Rate for Payer: BCN Commercial |
$89.36
|
| Rate for Payer: Cash Price |
$92.21
|
| Rate for Payer: Cofinity Commercial |
$108.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$92.21
|
| Rate for Payer: Healthscope Commercial |
$115.26
|
| Rate for Payer: Healthscope Whirlpool |
$111.80
|
| Rate for Payer: Mclaren Commercial |
$103.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$97.97
|
| Rate for Payer: Nomi Health Commercial |
$94.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$74.92
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$101.43
|
|
|
HC COMPLEMENT C 4
|
Facility
|
IP
|
$115.26
|
|
|
Service Code
|
CPT 86160
|
| Hospital Charge Code |
30200151
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$74.92 |
| Max. Negotiated Rate |
$115.26 |
| Rate for Payer: Aetna Commercial |
$103.73
|
| Rate for Payer: ASR ASR |
$111.80
|
| Rate for Payer: ASR Commercial |
$111.80
|
| Rate for Payer: BCBS Trust/PPO |
$93.93
|
| Rate for Payer: BCN Commercial |
$89.36
|
| Rate for Payer: Cash Price |
$92.21
|
| Rate for Payer: Cofinity Commercial |
$108.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$92.21
|
| Rate for Payer: Healthscope Commercial |
$115.26
|
| Rate for Payer: Healthscope Whirlpool |
$111.80
|
| Rate for Payer: Mclaren Commercial |
$103.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$97.97
|
| Rate for Payer: Nomi Health Commercial |
$94.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$74.92
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$101.43
|
|
