|
HC DGTZ GLS MCRSCP SLD LEVEL IV
|
Facility
|
IP
|
$19.09
|
|
|
Service Code
|
CPT 0753T
|
| Hospital Charge Code |
31200011
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$14.32 |
| Max. Negotiated Rate |
$19.09 |
| Rate for Payer: Aetna Commercial |
$17.18
|
| Rate for Payer: ASR ASR |
$18.52
|
| Rate for Payer: BCBS Trust/PPO |
$15.68
|
| Rate for Payer: BCN Commercial |
$15.68
|
| Rate for Payer: Cash Price |
$15.27
|
| Rate for Payer: Cofinity Commercial |
$17.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.27
|
| Rate for Payer: Healthscope Commercial |
$18.52
|
| Rate for Payer: Healthscope Whirlpool |
$19.09
|
| Rate for Payer: Mclaren Commercial |
$17.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.23
|
| Rate for Payer: Nomi Health Commercial |
$15.65
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$14.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.80
|
|
|
HC DGTZ GLS MCRSCP SLD LEVEL V
|
Facility
|
OP
|
$38.16
|
|
|
Service Code
|
CPT 0754T
|
| Hospital Charge Code |
31200012
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$14.12 |
| Max. Negotiated Rate |
$38.16 |
| Rate for Payer: Aetna Commercial |
$34.34
|
| Rate for Payer: Aetna Medicare |
$14.12
|
| Rate for Payer: ASR ASR |
$37.02
|
| Rate for Payer: BCBS Complete |
$15.26
|
| Rate for Payer: BCBS Trust/PPO |
$31.46
|
| Rate for Payer: BCN Commercial |
$31.46
|
| Rate for Payer: Cash Price |
$30.53
|
| Rate for Payer: Cofinity Commercial |
$35.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.53
|
| Rate for Payer: Healthscope Commercial |
$37.02
|
| Rate for Payer: Healthscope Whirlpool |
$38.16
|
| Rate for Payer: Mclaren Commercial |
$34.34
|
| Rate for Payer: MI Amish Medical Board Commercial |
$30.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$32.44
|
| Rate for Payer: Nomi Health Commercial |
$31.29
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$28.62
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$33.44
|
| Rate for Payer: Priority Health Narrow Network |
$26.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$33.58
|
|
|
HC DGTZ GLS MCRSCP SLD LEVEL V
|
Facility
|
IP
|
$38.16
|
|
|
Service Code
|
CPT 0754T
|
| Hospital Charge Code |
31200012
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$28.62 |
| Max. Negotiated Rate |
$38.16 |
| Rate for Payer: Aetna Commercial |
$34.34
|
| Rate for Payer: ASR ASR |
$37.02
|
| Rate for Payer: BCBS Trust/PPO |
$31.34
|
| Rate for Payer: BCN Commercial |
$31.34
|
| Rate for Payer: Cash Price |
$30.53
|
| Rate for Payer: Cofinity Commercial |
$35.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.53
|
| Rate for Payer: Healthscope Commercial |
$37.02
|
| Rate for Payer: Healthscope Whirlpool |
$38.16
|
| Rate for Payer: Mclaren Commercial |
$34.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$32.44
|
| Rate for Payer: Nomi Health Commercial |
$31.29
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$28.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$33.58
|
|
|
HC DGTZ GLS MCRSCP SLD LEVEL VI
|
Facility
|
IP
|
$38.16
|
|
|
Service Code
|
CPT 0755T
|
| Hospital Charge Code |
31200013
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$28.62 |
| Max. Negotiated Rate |
$38.16 |
| Rate for Payer: Aetna Commercial |
$34.34
|
| Rate for Payer: ASR ASR |
$37.02
|
| Rate for Payer: BCBS Trust/PPO |
$31.34
|
| Rate for Payer: BCN Commercial |
$31.34
|
| Rate for Payer: Cash Price |
$30.53
|
| Rate for Payer: Cofinity Commercial |
$35.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.53
|
| Rate for Payer: Healthscope Commercial |
$37.02
|
| Rate for Payer: Healthscope Whirlpool |
$38.16
|
| Rate for Payer: Mclaren Commercial |
$34.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$32.44
|
| Rate for Payer: Nomi Health Commercial |
$31.29
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$28.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$33.58
|
|
|
HC DGTZ GLS MCRSCP SLD LEVEL VI
|
Facility
|
OP
|
$38.16
|
|
|
Service Code
|
CPT 0755T
|
| Hospital Charge Code |
31200013
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$14.12 |
| Max. Negotiated Rate |
$38.16 |
| Rate for Payer: Aetna Commercial |
$34.34
|
| Rate for Payer: Aetna Medicare |
$14.12
|
| Rate for Payer: ASR ASR |
$37.02
|
| Rate for Payer: BCBS Complete |
$15.26
|
| Rate for Payer: BCBS Trust/PPO |
$31.46
|
| Rate for Payer: BCN Commercial |
$31.46
|
| Rate for Payer: Cash Price |
$30.53
|
| Rate for Payer: Cofinity Commercial |
$35.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.53
|
| Rate for Payer: Healthscope Commercial |
$37.02
|
| Rate for Payer: Healthscope Whirlpool |
$38.16
|
| Rate for Payer: Mclaren Commercial |
$34.34
|
| Rate for Payer: MI Amish Medical Board Commercial |
$30.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$32.44
|
| Rate for Payer: Nomi Health Commercial |
$31.29
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$28.62
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$33.44
|
| Rate for Payer: Priority Health Narrow Network |
$26.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$33.58
|
|
|
HC DGTZ GLS MCRSCP SLD LVL III
|
Facility
|
IP
|
$19.09
|
|
|
Service Code
|
CPT 0752T
|
| Hospital Charge Code |
31200010
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$14.32 |
| Max. Negotiated Rate |
$19.09 |
| Rate for Payer: Aetna Commercial |
$17.18
|
| Rate for Payer: ASR ASR |
$18.52
|
| Rate for Payer: BCBS Trust/PPO |
$15.68
|
| Rate for Payer: BCN Commercial |
$15.68
|
| Rate for Payer: Cash Price |
$15.27
|
| Rate for Payer: Cofinity Commercial |
$17.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.27
|
| Rate for Payer: Healthscope Commercial |
$18.52
|
| Rate for Payer: Healthscope Whirlpool |
$19.09
|
| Rate for Payer: Mclaren Commercial |
$17.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.23
|
| Rate for Payer: Nomi Health Commercial |
$15.65
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$14.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.80
|
|
|
HC DGTZ GLS MCRSCP SLD LVL III
|
Facility
|
OP
|
$19.09
|
|
|
Service Code
|
CPT 0752T
|
| Hospital Charge Code |
31200010
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$7.06 |
| Max. Negotiated Rate |
$19.09 |
| Rate for Payer: Aetna Commercial |
$17.18
|
| Rate for Payer: Aetna Medicare |
$7.06
|
| Rate for Payer: ASR ASR |
$18.52
|
| Rate for Payer: BCBS Complete |
$7.64
|
| Rate for Payer: BCBS Trust/PPO |
$15.74
|
| Rate for Payer: BCN Commercial |
$15.74
|
| Rate for Payer: Cash Price |
$15.27
|
| Rate for Payer: Cofinity Commercial |
$17.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.27
|
| Rate for Payer: Healthscope Commercial |
$18.52
|
| Rate for Payer: Healthscope Whirlpool |
$19.09
|
| Rate for Payer: Mclaren Commercial |
$17.18
|
| Rate for Payer: MI Amish Medical Board Commercial |
$15.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.23
|
| Rate for Payer: Nomi Health Commercial |
$15.65
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$14.32
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$16.73
|
| Rate for Payer: Priority Health Narrow Network |
$13.38
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.80
|
|
|
HC DGTZ GLS MCRSCP SLD SPC GRPI
|
Facility
|
OP
|
$19.09
|
|
|
Service Code
|
CPT 0756T
|
| Hospital Charge Code |
31200014
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$7.06 |
| Max. Negotiated Rate |
$19.09 |
| Rate for Payer: Aetna Commercial |
$17.18
|
| Rate for Payer: Aetna Medicare |
$7.06
|
| Rate for Payer: ASR ASR |
$18.52
|
| Rate for Payer: BCBS Complete |
$7.64
|
| Rate for Payer: BCBS Trust/PPO |
$15.74
|
| Rate for Payer: BCN Commercial |
$15.74
|
| Rate for Payer: Cash Price |
$15.27
|
| Rate for Payer: Cofinity Commercial |
$17.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.27
|
| Rate for Payer: Healthscope Commercial |
$18.52
|
| Rate for Payer: Healthscope Whirlpool |
$19.09
|
| Rate for Payer: Mclaren Commercial |
$17.18
|
| Rate for Payer: MI Amish Medical Board Commercial |
$15.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.23
|
| Rate for Payer: Nomi Health Commercial |
$15.65
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$14.32
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$16.73
|
| Rate for Payer: Priority Health Narrow Network |
$13.38
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.80
|
|
|
HC DGTZ GLS MCRSCP SLD SPC GRPI
|
Facility
|
IP
|
$19.09
|
|
|
Service Code
|
CPT 0756T
|
| Hospital Charge Code |
31200014
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$14.32 |
| Max. Negotiated Rate |
$19.09 |
| Rate for Payer: Aetna Commercial |
$17.18
|
| Rate for Payer: ASR ASR |
$18.52
|
| Rate for Payer: BCBS Trust/PPO |
$15.68
|
| Rate for Payer: BCN Commercial |
$15.68
|
| Rate for Payer: Cash Price |
$15.27
|
| Rate for Payer: Cofinity Commercial |
$17.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.27
|
| Rate for Payer: Healthscope Commercial |
$18.52
|
| Rate for Payer: Healthscope Whirlpool |
$19.09
|
| Rate for Payer: Mclaren Commercial |
$17.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.23
|
| Rate for Payer: Nomi Health Commercial |
$15.65
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$14.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.80
|
|
|
HC DGTZ GLS MCRSCP SL IMM 1ST
|
Facility
|
OP
|
$19.09
|
|
|
Service Code
|
CPT 0760T
|
| Hospital Charge Code |
31200018
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$7.06 |
| Max. Negotiated Rate |
$19.09 |
| Rate for Payer: Aetna Commercial |
$17.18
|
| Rate for Payer: Aetna Medicare |
$7.06
|
| Rate for Payer: ASR ASR |
$18.52
|
| Rate for Payer: BCBS Complete |
$7.64
|
| Rate for Payer: BCBS Trust/PPO |
$15.74
|
| Rate for Payer: BCN Commercial |
$15.74
|
| Rate for Payer: Cash Price |
$15.27
|
| Rate for Payer: Cofinity Commercial |
$17.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.27
|
| Rate for Payer: Healthscope Commercial |
$18.52
|
| Rate for Payer: Healthscope Whirlpool |
$19.09
|
| Rate for Payer: Mclaren Commercial |
$17.18
|
| Rate for Payer: MI Amish Medical Board Commercial |
$15.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.23
|
| Rate for Payer: Nomi Health Commercial |
$15.65
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$14.32
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$16.73
|
| Rate for Payer: Priority Health Narrow Network |
$13.38
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.80
|
|
|
HC DGTZ GLS MCRSCP SL IMM 1ST
|
Facility
|
IP
|
$19.09
|
|
|
Service Code
|
CPT 0760T
|
| Hospital Charge Code |
31200018
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$14.32 |
| Max. Negotiated Rate |
$19.09 |
| Rate for Payer: Aetna Commercial |
$17.18
|
| Rate for Payer: ASR ASR |
$18.52
|
| Rate for Payer: BCBS Trust/PPO |
$15.68
|
| Rate for Payer: BCN Commercial |
$15.68
|
| Rate for Payer: Cash Price |
$15.27
|
| Rate for Payer: Cofinity Commercial |
$17.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.27
|
| Rate for Payer: Healthscope Commercial |
$18.52
|
| Rate for Payer: Healthscope Whirlpool |
$19.09
|
| Rate for Payer: Mclaren Commercial |
$17.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.23
|
| Rate for Payer: Nomi Health Commercial |
$15.65
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$14.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.80
|
|
|
HC DGTZ GLS MCRSCP SL IMM EA 1
|
Facility
|
OP
|
$19.09
|
|
|
Service Code
|
CPT 0761T
|
| Hospital Charge Code |
31200019
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$7.06 |
| Max. Negotiated Rate |
$19.09 |
| Rate for Payer: Aetna Commercial |
$17.18
|
| Rate for Payer: Aetna Medicare |
$7.06
|
| Rate for Payer: ASR ASR |
$18.52
|
| Rate for Payer: BCBS Complete |
$7.64
|
| Rate for Payer: BCBS Trust/PPO |
$15.74
|
| Rate for Payer: BCN Commercial |
$15.74
|
| Rate for Payer: Cash Price |
$15.27
|
| Rate for Payer: Cofinity Commercial |
$17.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.27
|
| Rate for Payer: Healthscope Commercial |
$18.52
|
| Rate for Payer: Healthscope Whirlpool |
$19.09
|
| Rate for Payer: Mclaren Commercial |
$17.18
|
| Rate for Payer: MI Amish Medical Board Commercial |
$15.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.23
|
| Rate for Payer: Nomi Health Commercial |
$15.65
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$14.32
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$16.73
|
| Rate for Payer: Priority Health Narrow Network |
$13.38
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.80
|
|
|
HC DGTZ GLS MCRSCP SL IMM EA 1
|
Facility
|
IP
|
$19.09
|
|
|
Service Code
|
CPT 0761T
|
| Hospital Charge Code |
31200019
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$14.32 |
| Max. Negotiated Rate |
$19.09 |
| Rate for Payer: Aetna Commercial |
$17.18
|
| Rate for Payer: ASR ASR |
$18.52
|
| Rate for Payer: BCBS Trust/PPO |
$15.68
|
| Rate for Payer: BCN Commercial |
$15.68
|
| Rate for Payer: Cash Price |
$15.27
|
| Rate for Payer: Cofinity Commercial |
$17.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.27
|
| Rate for Payer: Healthscope Commercial |
$18.52
|
| Rate for Payer: Healthscope Whirlpool |
$19.09
|
| Rate for Payer: Mclaren Commercial |
$17.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.23
|
| Rate for Payer: Nomi Health Commercial |
$15.65
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$14.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.80
|
|
|
HC DGTZ GLS MCRSCP SL IMM EA M
|
Facility
|
OP
|
$19.09
|
|
|
Service Code
|
CPT 0762T
|
| Hospital Charge Code |
31200020
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$7.06 |
| Max. Negotiated Rate |
$19.09 |
| Rate for Payer: Aetna Commercial |
$17.18
|
| Rate for Payer: Aetna Medicare |
$7.06
|
| Rate for Payer: ASR ASR |
$18.52
|
| Rate for Payer: BCBS Complete |
$7.64
|
| Rate for Payer: BCBS Trust/PPO |
$15.74
|
| Rate for Payer: BCN Commercial |
$15.74
|
| Rate for Payer: Cash Price |
$15.27
|
| Rate for Payer: Cofinity Commercial |
$17.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.27
|
| Rate for Payer: Healthscope Commercial |
$18.52
|
| Rate for Payer: Healthscope Whirlpool |
$19.09
|
| Rate for Payer: Mclaren Commercial |
$17.18
|
| Rate for Payer: MI Amish Medical Board Commercial |
$15.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.23
|
| Rate for Payer: Nomi Health Commercial |
$15.65
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$14.32
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$16.73
|
| Rate for Payer: Priority Health Narrow Network |
$13.38
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.80
|
|
|
HC DGTZ GLS MCRSCP SL IMM EA M
|
Facility
|
IP
|
$19.09
|
|
|
Service Code
|
CPT 0762T
|
| Hospital Charge Code |
31200020
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$14.32 |
| Max. Negotiated Rate |
$19.09 |
| Rate for Payer: Aetna Commercial |
$17.18
|
| Rate for Payer: ASR ASR |
$18.52
|
| Rate for Payer: BCBS Trust/PPO |
$15.68
|
| Rate for Payer: BCN Commercial |
$15.68
|
| Rate for Payer: Cash Price |
$15.27
|
| Rate for Payer: Cofinity Commercial |
$17.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.27
|
| Rate for Payer: Healthscope Commercial |
$18.52
|
| Rate for Payer: Healthscope Whirlpool |
$19.09
|
| Rate for Payer: Mclaren Commercial |
$17.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.23
|
| Rate for Payer: Nomi Health Commercial |
$15.65
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$14.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.80
|
|
|
HC DGTZ GLS MCRSCP SL SPC GRPII
|
Facility
|
IP
|
$19.09
|
|
|
Service Code
|
CPT 0757T
|
| Hospital Charge Code |
31200015
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$14.32 |
| Max. Negotiated Rate |
$19.09 |
| Rate for Payer: Aetna Commercial |
$17.18
|
| Rate for Payer: ASR ASR |
$18.52
|
| Rate for Payer: BCBS Trust/PPO |
$15.68
|
| Rate for Payer: BCN Commercial |
$15.68
|
| Rate for Payer: Cash Price |
$15.27
|
| Rate for Payer: Cofinity Commercial |
$17.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.27
|
| Rate for Payer: Healthscope Commercial |
$18.52
|
| Rate for Payer: Healthscope Whirlpool |
$19.09
|
| Rate for Payer: Mclaren Commercial |
$17.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.23
|
| Rate for Payer: Nomi Health Commercial |
$15.65
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$14.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.80
|
|
|
HC DGTZ GLS MCRSCP SL SPC GRPII
|
Facility
|
OP
|
$19.09
|
|
|
Service Code
|
CPT 0757T
|
| Hospital Charge Code |
31200015
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$7.06 |
| Max. Negotiated Rate |
$19.09 |
| Rate for Payer: Aetna Commercial |
$17.18
|
| Rate for Payer: Aetna Medicare |
$7.06
|
| Rate for Payer: ASR ASR |
$18.52
|
| Rate for Payer: BCBS Complete |
$7.64
|
| Rate for Payer: BCBS Trust/PPO |
$15.74
|
| Rate for Payer: BCN Commercial |
$15.74
|
| Rate for Payer: Cash Price |
$15.27
|
| Rate for Payer: Cofinity Commercial |
$17.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.27
|
| Rate for Payer: Healthscope Commercial |
$18.52
|
| Rate for Payer: Healthscope Whirlpool |
$19.09
|
| Rate for Payer: Mclaren Commercial |
$17.18
|
| Rate for Payer: MI Amish Medical Board Commercial |
$15.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.23
|
| Rate for Payer: Nomi Health Commercial |
$15.65
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$14.32
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$16.73
|
| Rate for Payer: Priority Health Narrow Network |
$13.38
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.80
|
|
|
HC DGTZ GLS MCRSCP SL SPC HCHEM
|
Facility
|
IP
|
$19.09
|
|
|
Service Code
|
CPT 0758T
|
| Hospital Charge Code |
31200016
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$14.32 |
| Max. Negotiated Rate |
$19.09 |
| Rate for Payer: Aetna Commercial |
$17.18
|
| Rate for Payer: ASR ASR |
$18.52
|
| Rate for Payer: BCBS Trust/PPO |
$15.68
|
| Rate for Payer: BCN Commercial |
$15.68
|
| Rate for Payer: Cash Price |
$15.27
|
| Rate for Payer: Cofinity Commercial |
$17.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.27
|
| Rate for Payer: Healthscope Commercial |
$18.52
|
| Rate for Payer: Healthscope Whirlpool |
$19.09
|
| Rate for Payer: Mclaren Commercial |
$17.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.23
|
| Rate for Payer: Nomi Health Commercial |
$15.65
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$14.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.80
|
|
|
HC DGTZ GLS MCRSCP SL SPC HCHEM
|
Facility
|
OP
|
$19.09
|
|
|
Service Code
|
CPT 0758T
|
| Hospital Charge Code |
31200016
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$7.06 |
| Max. Negotiated Rate |
$19.09 |
| Rate for Payer: Aetna Commercial |
$17.18
|
| Rate for Payer: Aetna Medicare |
$7.06
|
| Rate for Payer: ASR ASR |
$18.52
|
| Rate for Payer: BCBS Complete |
$7.64
|
| Rate for Payer: BCBS Trust/PPO |
$15.74
|
| Rate for Payer: BCN Commercial |
$15.74
|
| Rate for Payer: Cash Price |
$15.27
|
| Rate for Payer: Cofinity Commercial |
$17.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.27
|
| Rate for Payer: Healthscope Commercial |
$18.52
|
| Rate for Payer: Healthscope Whirlpool |
$19.09
|
| Rate for Payer: Mclaren Commercial |
$17.18
|
| Rate for Payer: MI Amish Medical Board Commercial |
$15.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.23
|
| Rate for Payer: Nomi Health Commercial |
$15.65
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$14.32
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$16.73
|
| Rate for Payer: Priority Health Narrow Network |
$13.38
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.80
|
|
|
HC DGTZ GLS MCRSCP SL SP GRPIII
|
Facility
|
IP
|
$19.09
|
|
|
Service Code
|
CPT 0759T
|
| Hospital Charge Code |
31200017
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$14.32 |
| Max. Negotiated Rate |
$19.09 |
| Rate for Payer: Aetna Commercial |
$17.18
|
| Rate for Payer: ASR ASR |
$18.52
|
| Rate for Payer: BCBS Trust/PPO |
$15.68
|
| Rate for Payer: BCN Commercial |
$15.68
|
| Rate for Payer: Cash Price |
$15.27
|
| Rate for Payer: Cofinity Commercial |
$17.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.27
|
| Rate for Payer: Healthscope Commercial |
$18.52
|
| Rate for Payer: Healthscope Whirlpool |
$19.09
|
| Rate for Payer: Mclaren Commercial |
$17.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.23
|
| Rate for Payer: Nomi Health Commercial |
$15.65
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$14.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.80
|
|
|
HC DGTZ GLS MCRSCP SL SP GRPIII
|
Facility
|
OP
|
$19.09
|
|
|
Service Code
|
CPT 0759T
|
| Hospital Charge Code |
31200017
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$7.06 |
| Max. Negotiated Rate |
$19.09 |
| Rate for Payer: Aetna Commercial |
$17.18
|
| Rate for Payer: Aetna Medicare |
$7.06
|
| Rate for Payer: ASR ASR |
$18.52
|
| Rate for Payer: BCBS Complete |
$7.64
|
| Rate for Payer: BCBS Trust/PPO |
$15.74
|
| Rate for Payer: BCN Commercial |
$15.74
|
| Rate for Payer: Cash Price |
$15.27
|
| Rate for Payer: Cofinity Commercial |
$17.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.27
|
| Rate for Payer: Healthscope Commercial |
$18.52
|
| Rate for Payer: Healthscope Whirlpool |
$19.09
|
| Rate for Payer: Mclaren Commercial |
$17.18
|
| Rate for Payer: MI Amish Medical Board Commercial |
$15.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.23
|
| Rate for Payer: Nomi Health Commercial |
$15.65
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$14.32
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$16.73
|
| Rate for Payer: Priority Health Narrow Network |
$13.38
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.80
|
|
|
HC DHEA
|
Facility
|
IP
|
$52.00
|
|
|
Service Code
|
CPT 82626
|
| Hospital Charge Code |
30100187
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$39.00 |
| Max. Negotiated Rate |
$52.00 |
| Rate for Payer: Aetna Commercial |
$46.80
|
| Rate for Payer: ASR ASR |
$50.44
|
| Rate for Payer: BCBS Trust/PPO |
$42.70
|
| Rate for Payer: BCN Commercial |
$42.70
|
| Rate for Payer: Cash Price |
$41.60
|
| Rate for Payer: Cofinity Commercial |
$48.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$41.60
|
| Rate for Payer: Healthscope Commercial |
$50.44
|
| Rate for Payer: Healthscope Whirlpool |
$52.00
|
| Rate for Payer: Mclaren Commercial |
$46.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$44.20
|
| Rate for Payer: Nomi Health Commercial |
$42.64
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$39.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$45.76
|
|
|
HC DHEA
|
Facility
|
OP
|
$52.00
|
|
|
Service Code
|
CPT 82626
|
| Hospital Charge Code |
30100187
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$13.22 |
| Max. Negotiated Rate |
$173.10 |
| Rate for Payer: Aetna Commercial |
$46.80
|
| Rate for Payer: Aetna Medicare |
$25.27
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$31.59
|
| Rate for Payer: Amish Plain Church Group Commercial |
$31.59
|
| Rate for Payer: ASR ASR |
$50.44
|
| Rate for Payer: BCBS Complete |
$13.88
|
| Rate for Payer: BCBS MAPPO |
$25.27
|
| Rate for Payer: BCBS Trust/PPO |
$42.87
|
| Rate for Payer: BCN Commercial |
$42.87
|
| Rate for Payer: BCN Medicare Advantage |
$25.27
|
| Rate for Payer: Cash Price |
$41.60
|
| Rate for Payer: Cash Price |
$41.60
|
| Rate for Payer: Cofinity Commercial |
$48.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$41.60
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$25.27
|
| Rate for Payer: Healthscope Commercial |
$50.44
|
| Rate for Payer: Healthscope Whirlpool |
$52.00
|
| Rate for Payer: Humana Choice PPO Medicare |
$25.27
|
| Rate for Payer: Mclaren Commercial |
$46.80
|
| Rate for Payer: Mclaren Medicaid |
$25.27
|
| Rate for Payer: Mclaren Medicare |
$25.27
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$26.53
|
| Rate for Payer: Meridian Medicaid |
$13.88
|
| Rate for Payer: MI Amish Medical Board Commercial |
$29.06
|
| Rate for Payer: Molina Medicare/Medicaid |
$27.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$44.20
|
| Rate for Payer: Nomi Health Commercial |
$42.64
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$39.00
|
| Rate for Payer: PACE Medicare |
$24.01
|
| Rate for Payer: PACE SWMI |
$25.27
|
| Rate for Payer: PHP Commercial |
$27.80
|
| Rate for Payer: PHP Medicaid |
$13.54
|
| Rate for Payer: PHP Medicare Advantage |
$25.27
|
| Rate for Payer: Priority Health Choice Medicaid |
$13.22
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$173.10
|
| Rate for Payer: Priority Health Medicare |
$25.27
|
| Rate for Payer: Priority Health Narrow Network |
$138.48
|
| Rate for Payer: Railroad Medicare Medicare |
$25.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$45.76
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$25.27
|
| Rate for Payer: UHC Exchange |
$39.17
|
| Rate for Payer: UHC Medicaid |
$13.22
|
| Rate for Payer: UHCCP DNSP |
$25.27
|
| Rate for Payer: UHCCP Medicaid |
$13.22
|
| Rate for Payer: VA VA |
$25.27
|
|
|
HC DHEA-SULFATE
|
Facility
|
OP
|
$57.30
|
|
|
Service Code
|
CPT 82627
|
| Hospital Charge Code |
30100188
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$11.63 |
| Max. Negotiated Rate |
$76.27 |
| Rate for Payer: Aetna Commercial |
$51.57
|
| Rate for Payer: Aetna Medicare |
$22.23
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$27.79
|
| Rate for Payer: Amish Plain Church Group Commercial |
$27.79
|
| Rate for Payer: ASR ASR |
$55.58
|
| Rate for Payer: BCBS Complete |
$12.21
|
| Rate for Payer: BCBS MAPPO |
$22.23
|
| Rate for Payer: BCBS Trust/PPO |
$47.24
|
| Rate for Payer: BCN Commercial |
$47.24
|
| Rate for Payer: BCN Medicare Advantage |
$22.23
|
| Rate for Payer: Cash Price |
$45.84
|
| Rate for Payer: Cash Price |
$45.84
|
| Rate for Payer: Cofinity Commercial |
$53.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$45.84
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$22.23
|
| Rate for Payer: Healthscope Commercial |
$55.58
|
| Rate for Payer: Healthscope Whirlpool |
$57.30
|
| Rate for Payer: Humana Choice PPO Medicare |
$22.23
|
| Rate for Payer: Mclaren Commercial |
$51.57
|
| Rate for Payer: Mclaren Medicaid |
$22.23
|
| Rate for Payer: Mclaren Medicare |
$22.23
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$23.34
|
| Rate for Payer: Meridian Medicaid |
$12.21
|
| Rate for Payer: MI Amish Medical Board Commercial |
$25.56
|
| Rate for Payer: Molina Medicare/Medicaid |
$24.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$48.70
|
| Rate for Payer: Nomi Health Commercial |
$46.99
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$42.98
|
| Rate for Payer: PACE Medicare |
$21.12
|
| Rate for Payer: PACE SWMI |
$22.23
|
| Rate for Payer: PHP Commercial |
$24.45
|
| Rate for Payer: PHP Medicaid |
$11.92
|
| Rate for Payer: PHP Medicare Advantage |
$22.23
|
| Rate for Payer: Priority Health Choice Medicaid |
$11.63
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$76.27
|
| Rate for Payer: Priority Health Medicare |
$22.23
|
| Rate for Payer: Priority Health Narrow Network |
$61.02
|
| Rate for Payer: Railroad Medicare Medicare |
$22.23
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$50.42
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$22.23
|
| Rate for Payer: UHC Exchange |
$34.46
|
| Rate for Payer: UHC Medicaid |
$11.63
|
| Rate for Payer: UHCCP DNSP |
$22.23
|
| Rate for Payer: UHCCP Medicaid |
$11.63
|
| Rate for Payer: VA VA |
$22.23
|
|
|
HC DHEA-SULFATE
|
Facility
|
IP
|
$57.30
|
|
|
Service Code
|
CPT 82627
|
| Hospital Charge Code |
30100188
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$42.98 |
| Max. Negotiated Rate |
$57.30 |
| Rate for Payer: Aetna Commercial |
$51.57
|
| Rate for Payer: ASR ASR |
$55.58
|
| Rate for Payer: BCBS Trust/PPO |
$47.05
|
| Rate for Payer: BCN Commercial |
$47.05
|
| Rate for Payer: Cash Price |
$45.84
|
| Rate for Payer: Cofinity Commercial |
$53.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$45.84
|
| Rate for Payer: Healthscope Commercial |
$55.58
|
| Rate for Payer: Healthscope Whirlpool |
$57.30
|
| Rate for Payer: Mclaren Commercial |
$51.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$48.70
|
| Rate for Payer: Nomi Health Commercial |
$46.99
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$42.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$50.42
|
|
