|
HC INFLUENZA A AND B PCR
|
Facility
|
OP
|
$212.70
|
|
|
Service Code
|
CPT 87631
|
| Hospital Charge Code |
30600207
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$78.02 |
| Max. Negotiated Rate |
$212.70 |
| Rate for Payer: Aetna Commercial |
$191.43
|
| Rate for Payer: Aetna Medicare |
$142.63
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$178.29
|
| Rate for Payer: Amish Plain Church Group Commercial |
$178.29
|
| Rate for Payer: ASR ASR |
$206.32
|
| Rate for Payer: BCBS Complete |
$81.93
|
| Rate for Payer: BCBS MAPPO |
$142.63
|
| Rate for Payer: BCBS Trust/PPO |
$164.91
|
| Rate for Payer: BCN Commercial |
$164.91
|
| Rate for Payer: BCN Medicare Advantage |
$142.63
|
| Rate for Payer: Cash Price |
$170.16
|
| Rate for Payer: Cash Price |
$170.16
|
| Rate for Payer: Cofinity Commercial |
$199.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$170.16
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$142.63
|
| Rate for Payer: Healthscope Commercial |
$212.70
|
| Rate for Payer: Healthscope Whirlpool |
$206.32
|
| Rate for Payer: Humana Choice PPO Medicare |
$142.63
|
| Rate for Payer: Mclaren Commercial |
$191.43
|
| Rate for Payer: Mclaren Medicaid |
$78.02
|
| Rate for Payer: Mclaren Medicare |
$142.63
|
| Rate for Payer: Meridian Medicaid |
$81.93
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$149.76
|
| Rate for Payer: MI Amish Medical Board Commercial |
$164.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$180.80
|
| Rate for Payer: PACE Medicare |
$135.50
|
| Rate for Payer: PACE SWMI |
$142.63
|
| Rate for Payer: PHP Commercial |
$156.89
|
| Rate for Payer: PHP Medicaid |
$78.02
|
| Rate for Payer: PHP Medicare Advantage |
$142.63
|
| Rate for Payer: Priority Health Choice Medicaid |
$78.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$148.89
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$207.55
|
| Rate for Payer: Priority Health Medicare |
$142.63
|
| Rate for Payer: Priority Health Narrow Network |
$166.04
|
| Rate for Payer: Railroad Medicare Medicare |
$142.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$187.18
|
| Rate for Payer: UHC Medicare Advantage |
$146.91
|
| Rate for Payer: VA VA |
$142.63
|
|
|
HC INFLUENZA A AND B PCR
|
Facility
|
IP
|
$212.70
|
|
|
Service Code
|
CPT 87631
|
| Hospital Charge Code |
30600207
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$148.89 |
| Max. Negotiated Rate |
$212.70 |
| Rate for Payer: Aetna Commercial |
$191.43
|
| Rate for Payer: ASR ASR |
$206.32
|
| Rate for Payer: BCBS Trust/PPO |
$164.91
|
| Rate for Payer: BCN Commercial |
$164.91
|
| Rate for Payer: Cash Price |
$170.16
|
| Rate for Payer: Cofinity Commercial |
$199.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$170.16
|
| Rate for Payer: Healthscope Commercial |
$212.70
|
| Rate for Payer: Healthscope Whirlpool |
$206.32
|
| Rate for Payer: Mclaren Commercial |
$191.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$180.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$148.89
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$187.18
|
|
|
HC INFLUENZA A/B DNA AMP PROBE
|
Facility
|
OP
|
$142.87
|
|
|
Service Code
|
CPT 87502
|
| Hospital Charge Code |
30600314
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$52.40 |
| Max. Negotiated Rate |
$142.87 |
| Rate for Payer: Aetna Commercial |
$128.58
|
| Rate for Payer: Aetna Medicare |
$95.80
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$119.75
|
| Rate for Payer: Amish Plain Church Group Commercial |
$119.75
|
| Rate for Payer: ASR ASR |
$138.58
|
| Rate for Payer: BCBS Complete |
$55.03
|
| Rate for Payer: BCBS MAPPO |
$95.80
|
| Rate for Payer: BCBS Trust/PPO |
$110.77
|
| Rate for Payer: BCN Commercial |
$110.77
|
| Rate for Payer: BCN Medicare Advantage |
$95.80
|
| Rate for Payer: Cash Price |
$114.30
|
| Rate for Payer: Cash Price |
$114.30
|
| Rate for Payer: Cofinity Commercial |
$134.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$114.30
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$95.80
|
| Rate for Payer: Healthscope Commercial |
$142.87
|
| Rate for Payer: Healthscope Whirlpool |
$138.58
|
| Rate for Payer: Humana Choice PPO Medicare |
$95.80
|
| Rate for Payer: Mclaren Commercial |
$128.58
|
| Rate for Payer: Mclaren Medicaid |
$52.40
|
| Rate for Payer: Mclaren Medicare |
$95.80
|
| Rate for Payer: Meridian Medicaid |
$55.03
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$100.59
|
| Rate for Payer: MI Amish Medical Board Commercial |
$110.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$121.44
|
| Rate for Payer: PACE Medicare |
$91.01
|
| Rate for Payer: PACE SWMI |
$95.80
|
| Rate for Payer: PHP Commercial |
$105.38
|
| Rate for Payer: PHP Medicaid |
$52.40
|
| Rate for Payer: PHP Medicare Advantage |
$95.80
|
| Rate for Payer: Priority Health Choice Medicaid |
$52.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$100.01
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$130.01
|
| Rate for Payer: Priority Health Medicare |
$95.80
|
| Rate for Payer: Priority Health Narrow Network |
$101.44
|
| Rate for Payer: Railroad Medicare Medicare |
$95.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$125.73
|
| Rate for Payer: UHC Medicare Advantage |
$98.67
|
| Rate for Payer: VA VA |
$95.80
|
|
|
HC INFLUENZA A/B DNA AMP PROBE
|
Facility
|
IP
|
$142.87
|
|
|
Service Code
|
CPT 87502
|
| Hospital Charge Code |
30600314
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$100.01 |
| Max. Negotiated Rate |
$142.87 |
| Rate for Payer: Aetna Commercial |
$128.58
|
| Rate for Payer: ASR ASR |
$138.58
|
| Rate for Payer: BCBS Trust/PPO |
$110.77
|
| Rate for Payer: BCN Commercial |
$110.77
|
| Rate for Payer: Cash Price |
$114.30
|
| Rate for Payer: Cofinity Commercial |
$134.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$114.30
|
| Rate for Payer: Healthscope Commercial |
$142.87
|
| Rate for Payer: Healthscope Whirlpool |
$138.58
|
| Rate for Payer: Mclaren Commercial |
$128.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$121.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$100.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$125.73
|
|
|
HC INFLUENZA AND RSV BY PCR
|
Facility
|
IP
|
$218.96
|
|
|
Service Code
|
CPT 87631
|
| Hospital Charge Code |
30600213
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$153.27 |
| Max. Negotiated Rate |
$218.96 |
| Rate for Payer: Aetna Commercial |
$197.06
|
| Rate for Payer: ASR ASR |
$212.39
|
| Rate for Payer: BCBS Trust/PPO |
$169.76
|
| Rate for Payer: BCN Commercial |
$169.76
|
| Rate for Payer: Cash Price |
$175.17
|
| Rate for Payer: Cofinity Commercial |
$205.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$175.17
|
| Rate for Payer: Healthscope Commercial |
$218.96
|
| Rate for Payer: Healthscope Whirlpool |
$212.39
|
| Rate for Payer: Mclaren Commercial |
$197.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$186.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$153.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$192.68
|
|
|
HC INFLUENZA AND RSV BY PCR
|
Facility
|
OP
|
$218.96
|
|
|
Service Code
|
CPT 87631
|
| Hospital Charge Code |
30600213
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$78.02 |
| Max. Negotiated Rate |
$218.96 |
| Rate for Payer: Aetna Commercial |
$197.06
|
| Rate for Payer: Aetna Medicare |
$142.63
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$178.29
|
| Rate for Payer: Amish Plain Church Group Commercial |
$178.29
|
| Rate for Payer: ASR ASR |
$212.39
|
| Rate for Payer: BCBS Complete |
$81.93
|
| Rate for Payer: BCBS MAPPO |
$142.63
|
| Rate for Payer: BCBS Trust/PPO |
$169.76
|
| Rate for Payer: BCN Commercial |
$169.76
|
| Rate for Payer: BCN Medicare Advantage |
$142.63
|
| Rate for Payer: Cash Price |
$175.17
|
| Rate for Payer: Cash Price |
$175.17
|
| Rate for Payer: Cofinity Commercial |
$205.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$175.17
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$142.63
|
| Rate for Payer: Healthscope Commercial |
$218.96
|
| Rate for Payer: Healthscope Whirlpool |
$212.39
|
| Rate for Payer: Humana Choice PPO Medicare |
$142.63
|
| Rate for Payer: Mclaren Commercial |
$197.06
|
| Rate for Payer: Mclaren Medicaid |
$78.02
|
| Rate for Payer: Mclaren Medicare |
$142.63
|
| Rate for Payer: Meridian Medicaid |
$81.93
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$149.76
|
| Rate for Payer: MI Amish Medical Board Commercial |
$164.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$186.12
|
| Rate for Payer: PACE Medicare |
$135.50
|
| Rate for Payer: PACE SWMI |
$142.63
|
| Rate for Payer: PHP Commercial |
$156.89
|
| Rate for Payer: PHP Medicaid |
$78.02
|
| Rate for Payer: PHP Medicare Advantage |
$142.63
|
| Rate for Payer: Priority Health Choice Medicaid |
$78.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$153.27
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$207.55
|
| Rate for Payer: Priority Health Medicare |
$142.63
|
| Rate for Payer: Priority Health Narrow Network |
$166.04
|
| Rate for Payer: Railroad Medicare Medicare |
$142.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$192.68
|
| Rate for Payer: UHC Medicare Advantage |
$146.91
|
| Rate for Payer: VA VA |
$142.63
|
|
|
HC INFLUENZA INJECTION
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
HCPCS G0008
|
| Hospital Charge Code |
77100009
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$21.00 |
| Max. Negotiated Rate |
$30.00 |
| Rate for Payer: Aetna Commercial |
$27.00
|
| Rate for Payer: ASR ASR |
$29.10
|
| Rate for Payer: BCBS Trust/PPO |
$23.26
|
| Rate for Payer: BCN Commercial |
$23.26
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cofinity Commercial |
$28.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$24.00
|
| Rate for Payer: Healthscope Commercial |
$30.00
|
| Rate for Payer: Healthscope Whirlpool |
$29.10
|
| Rate for Payer: Mclaren Commercial |
$27.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$25.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$26.40
|
|
|
HC INFLUENZA INJECTION
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
HCPCS G0008
|
| Hospital Charge Code |
77100009
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$13.74 |
| Max. Negotiated Rate |
$52.78 |
| Rate for Payer: Aetna Commercial |
$27.00
|
| Rate for Payer: Aetna Medicare |
$42.22
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$52.78
|
| Rate for Payer: Amish Plain Church Group Commercial |
$52.78
|
| Rate for Payer: ASR ASR |
$29.10
|
| Rate for Payer: BCBS Complete |
$24.25
|
| Rate for Payer: BCBS MAPPO |
$42.22
|
| Rate for Payer: BCBS Trust/PPO |
$23.26
|
| Rate for Payer: BCN Commercial |
$23.26
|
| Rate for Payer: BCN Medicare Advantage |
$42.22
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cofinity Commercial |
$28.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$24.00
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$42.22
|
| Rate for Payer: Healthscope Commercial |
$30.00
|
| Rate for Payer: Healthscope Whirlpool |
$29.10
|
| Rate for Payer: Humana Choice PPO Medicare |
$42.22
|
| Rate for Payer: Mclaren Commercial |
$27.00
|
| Rate for Payer: Mclaren Medicaid |
$23.09
|
| Rate for Payer: Mclaren Medicare |
$42.22
|
| Rate for Payer: Meridian Medicaid |
$24.25
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$44.33
|
| Rate for Payer: MI Amish Medical Board Commercial |
$48.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$25.50
|
| Rate for Payer: PACE Medicare |
$40.11
|
| Rate for Payer: PACE SWMI |
$42.22
|
| Rate for Payer: PHP Commercial |
$46.44
|
| Rate for Payer: PHP Medicaid |
$23.09
|
| Rate for Payer: PHP Medicare Advantage |
$42.22
|
| Rate for Payer: Priority Health Choice Medicaid |
$23.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.00
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$17.18
|
| Rate for Payer: Priority Health Medicare |
$42.22
|
| Rate for Payer: Priority Health Narrow Network |
$13.74
|
| Rate for Payer: Railroad Medicare Medicare |
$42.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$26.40
|
| Rate for Payer: UHC Medicare Advantage |
$43.49
|
| Rate for Payer: VA VA |
$42.22
|
|
|
HC INFLUENZA VIRUS VACCINE (IIV), SPLIT VIRUS, PRESERVATIVE FREE IM
|
Facility
|
IP
|
$69.36
|
|
|
Service Code
|
CPT 90662
|
| Hospital Charge Code |
63600073
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.55 |
| Max. Negotiated Rate |
$69.36 |
| Rate for Payer: Aetna Commercial |
$62.42
|
| Rate for Payer: ASR ASR |
$67.28
|
| Rate for Payer: BCBS Trust/PPO |
$53.77
|
| Rate for Payer: BCN Commercial |
$53.77
|
| Rate for Payer: Cash Price |
$55.49
|
| Rate for Payer: Cofinity Commercial |
$65.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$55.49
|
| Rate for Payer: Healthscope Commercial |
$69.36
|
| Rate for Payer: Healthscope Whirlpool |
$67.28
|
| Rate for Payer: Mclaren Commercial |
$62.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$58.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$48.55
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$61.04
|
|
|
HC INFLUENZA VIRUS VACCINE (IIV), SPLIT VIRUS, PRESERVATIVE FREE IM
|
Facility
|
OP
|
$69.36
|
|
|
Service Code
|
CPT 90662
|
| Hospital Charge Code |
63600073
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.74 |
| Max. Negotiated Rate |
$69.36 |
| Rate for Payer: Aetna Commercial |
$62.42
|
| Rate for Payer: ASR ASR |
$67.28
|
| Rate for Payer: BCBS Complete |
$27.74
|
| Rate for Payer: BCBS Trust/PPO |
$53.77
|
| Rate for Payer: BCN Commercial |
$53.77
|
| Rate for Payer: Cash Price |
$55.49
|
| Rate for Payer: Cofinity Commercial |
$65.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$55.49
|
| Rate for Payer: Healthscope Commercial |
$69.36
|
| Rate for Payer: Healthscope Whirlpool |
$67.28
|
| Rate for Payer: Mclaren Commercial |
$62.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$58.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$48.55
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$63.12
|
| Rate for Payer: Priority Health Narrow Network |
$49.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$61.04
|
|
|
HC INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT VIRUS, 0.5 ML IM
|
Facility
|
IP
|
$25.50
|
|
|
Service Code
|
CPT 90688
|
| Hospital Charge Code |
63600079
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.85 |
| Max. Negotiated Rate |
$25.50 |
| Rate for Payer: Aetna Commercial |
$22.95
|
| Rate for Payer: ASR ASR |
$24.74
|
| Rate for Payer: BCBS Trust/PPO |
$19.77
|
| Rate for Payer: BCN Commercial |
$19.77
|
| Rate for Payer: Cash Price |
$20.40
|
| Rate for Payer: Cofinity Commercial |
$23.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.40
|
| Rate for Payer: Healthscope Commercial |
$25.50
|
| Rate for Payer: Healthscope Whirlpool |
$24.74
|
| Rate for Payer: Mclaren Commercial |
$22.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$22.44
|
|
|
HC INFLUENZA VIRUS VACCINE, QUADRIVALENT (IIV4), SPLIT VIRUS, 0.5 ML IM
|
Facility
|
OP
|
$25.50
|
|
|
Service Code
|
CPT 90688
|
| Hospital Charge Code |
63600079
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$25.50 |
| Rate for Payer: Aetna Commercial |
$22.95
|
| Rate for Payer: ASR ASR |
$24.74
|
| Rate for Payer: BCBS Complete |
$10.20
|
| Rate for Payer: BCBS Trust/PPO |
$19.77
|
| Rate for Payer: BCN Commercial |
$19.77
|
| Rate for Payer: Cash Price |
$20.40
|
| Rate for Payer: Cash Price |
$20.40
|
| Rate for Payer: Cofinity Commercial |
$23.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.40
|
| Rate for Payer: Healthscope Commercial |
$25.50
|
| Rate for Payer: Healthscope Whirlpool |
$24.74
|
| Rate for Payer: Mclaren Commercial |
$22.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.85
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$0.01
|
| Rate for Payer: Priority Health Narrow Network |
$0.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$22.44
|
|
|
HC INFLUENZA VIRUS VACCINE, QUADRIVALENT, LIVE (LAIV4) INTRANASAL
|
Facility
|
IP
|
$31.62
|
|
|
Service Code
|
CPT 90672
|
| Hospital Charge Code |
63600075
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.13 |
| Max. Negotiated Rate |
$31.62 |
| Rate for Payer: Aetna Commercial |
$28.46
|
| Rate for Payer: ASR ASR |
$30.67
|
| Rate for Payer: BCBS Trust/PPO |
$24.51
|
| Rate for Payer: BCN Commercial |
$24.51
|
| Rate for Payer: Cash Price |
$25.30
|
| Rate for Payer: Cofinity Commercial |
$29.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25.30
|
| Rate for Payer: Healthscope Commercial |
$31.62
|
| Rate for Payer: Healthscope Whirlpool |
$30.67
|
| Rate for Payer: Mclaren Commercial |
$28.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$26.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$27.83
|
|
|
HC INFLUENZA VIRUS VACCINE, QUADRIVALENT, LIVE (LAIV4) INTRANASAL
|
Facility
|
OP
|
$31.62
|
|
|
Service Code
|
CPT 90672
|
| Hospital Charge Code |
63600075
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$31.62 |
| Rate for Payer: Aetna Commercial |
$28.46
|
| Rate for Payer: ASR ASR |
$30.67
|
| Rate for Payer: BCBS Complete |
$12.65
|
| Rate for Payer: BCBS Trust/PPO |
$24.51
|
| Rate for Payer: BCN Commercial |
$24.51
|
| Rate for Payer: Cash Price |
$25.30
|
| Rate for Payer: Cash Price |
$25.30
|
| Rate for Payer: Cofinity Commercial |
$29.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25.30
|
| Rate for Payer: Healthscope Commercial |
$31.62
|
| Rate for Payer: Healthscope Whirlpool |
$30.67
|
| Rate for Payer: Mclaren Commercial |
$28.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$26.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.13
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$0.01
|
| Rate for Payer: Priority Health Narrow Network |
$0.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$27.83
|
|
|
HC INFLUENZA VIRUS VAC, QUAD (IIV4), SPLIT VIRUS, 0.25 ML IM
|
Facility
|
OP
|
$25.50
|
|
|
Service Code
|
CPT 90687
|
| Hospital Charge Code |
63600126
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$25.50 |
| Rate for Payer: Aetna Commercial |
$22.95
|
| Rate for Payer: ASR ASR |
$24.74
|
| Rate for Payer: BCBS Complete |
$10.20
|
| Rate for Payer: BCBS Trust/PPO |
$19.77
|
| Rate for Payer: BCN Commercial |
$19.77
|
| Rate for Payer: Cash Price |
$20.40
|
| Rate for Payer: Cash Price |
$20.40
|
| Rate for Payer: Cofinity Commercial |
$23.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.40
|
| Rate for Payer: Healthscope Commercial |
$25.50
|
| Rate for Payer: Healthscope Whirlpool |
$24.74
|
| Rate for Payer: Mclaren Commercial |
$22.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.85
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$0.01
|
| Rate for Payer: Priority Health Narrow Network |
$0.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$22.44
|
|
|
HC INFLUENZA VIRUS VAC, QUAD (IIV4), SPLIT VIRUS, 0.25 ML IM
|
Facility
|
IP
|
$25.50
|
|
|
Service Code
|
CPT 90687
|
| Hospital Charge Code |
63600126
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.85 |
| Max. Negotiated Rate |
$25.50 |
| Rate for Payer: Aetna Commercial |
$22.95
|
| Rate for Payer: ASR ASR |
$24.74
|
| Rate for Payer: BCBS Trust/PPO |
$19.77
|
| Rate for Payer: BCN Commercial |
$19.77
|
| Rate for Payer: Cash Price |
$20.40
|
| Rate for Payer: Cofinity Commercial |
$23.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.40
|
| Rate for Payer: Healthscope Commercial |
$25.50
|
| Rate for Payer: Healthscope Whirlpool |
$24.74
|
| Rate for Payer: Mclaren Commercial |
$22.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$22.44
|
|
|
HC INFLUENZA VIRUS VAC, QUAD (IIV4), SPLIT VIRUS, PF, 0.5 ML IM
|
Facility
|
OP
|
$25.50
|
|
|
Service Code
|
CPT 90686
|
| Hospital Charge Code |
63600078
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$25.50 |
| Rate for Payer: Aetna Commercial |
$22.95
|
| Rate for Payer: ASR ASR |
$24.74
|
| Rate for Payer: BCBS Complete |
$10.20
|
| Rate for Payer: BCBS Trust/PPO |
$19.77
|
| Rate for Payer: BCN Commercial |
$19.77
|
| Rate for Payer: Cash Price |
$20.40
|
| Rate for Payer: Cash Price |
$20.40
|
| Rate for Payer: Cofinity Commercial |
$23.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.40
|
| Rate for Payer: Healthscope Commercial |
$25.50
|
| Rate for Payer: Healthscope Whirlpool |
$24.74
|
| Rate for Payer: Mclaren Commercial |
$22.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.85
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$0.01
|
| Rate for Payer: Priority Health Narrow Network |
$0.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$22.44
|
|
|
HC INFLUENZA VIRUS VAC, QUAD (IIV4), SPLIT VIRUS, PF, 0.5 ML IM
|
Facility
|
IP
|
$25.50
|
|
|
Service Code
|
CPT 90686
|
| Hospital Charge Code |
63600078
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.85 |
| Max. Negotiated Rate |
$25.50 |
| Rate for Payer: Aetna Commercial |
$22.95
|
| Rate for Payer: ASR ASR |
$24.74
|
| Rate for Payer: BCBS Trust/PPO |
$19.77
|
| Rate for Payer: BCN Commercial |
$19.77
|
| Rate for Payer: Cash Price |
$20.40
|
| Rate for Payer: Cofinity Commercial |
$23.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.40
|
| Rate for Payer: Healthscope Commercial |
$25.50
|
| Rate for Payer: Healthscope Whirlpool |
$24.74
|
| Rate for Payer: Mclaren Commercial |
$22.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$22.44
|
|
|
HC INFLUENZA VIRUS VAC, QUAD (IIV4), SPLIT VIRUS, PF, CHILD 6-35 MONTHS, IM
|
Facility
|
IP
|
$25.50
|
|
|
Service Code
|
CPT 90685
|
| Hospital Charge Code |
63600077
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.85 |
| Max. Negotiated Rate |
$25.50 |
| Rate for Payer: Aetna Commercial |
$22.95
|
| Rate for Payer: ASR ASR |
$24.74
|
| Rate for Payer: BCBS Trust/PPO |
$19.77
|
| Rate for Payer: BCN Commercial |
$19.77
|
| Rate for Payer: Cash Price |
$20.40
|
| Rate for Payer: Cofinity Commercial |
$23.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.40
|
| Rate for Payer: Healthscope Commercial |
$25.50
|
| Rate for Payer: Healthscope Whirlpool |
$24.74
|
| Rate for Payer: Mclaren Commercial |
$22.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$22.44
|
|
|
HC INFLUENZA VIRUS VAC, QUAD (IIV4), SPLIT VIRUS, PF, CHILD 6-35 MONTHS, IM
|
Facility
|
OP
|
$25.50
|
|
|
Service Code
|
CPT 90685
|
| Hospital Charge Code |
63600077
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$25.50 |
| Rate for Payer: Aetna Commercial |
$22.95
|
| Rate for Payer: ASR ASR |
$24.74
|
| Rate for Payer: BCBS Complete |
$10.20
|
| Rate for Payer: BCBS Trust/PPO |
$19.77
|
| Rate for Payer: BCN Commercial |
$19.77
|
| Rate for Payer: Cash Price |
$20.40
|
| Rate for Payer: Cash Price |
$20.40
|
| Rate for Payer: Cofinity Commercial |
$23.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.40
|
| Rate for Payer: Healthscope Commercial |
$25.50
|
| Rate for Payer: Healthscope Whirlpool |
$24.74
|
| Rate for Payer: Mclaren Commercial |
$22.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.85
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$0.01
|
| Rate for Payer: Priority Health Narrow Network |
$0.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$22.44
|
|
|
HC INFLUENZA VIRUS VAC, TRIVALENT (IIV3), SPLIT VIRUS PF, 0.5 ML IM
|
Facility
|
IP
|
$24.48
|
|
|
Service Code
|
CPT 90656
|
| Hospital Charge Code |
63600072
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.14 |
| Max. Negotiated Rate |
$24.48 |
| Rate for Payer: Aetna Commercial |
$22.03
|
| Rate for Payer: ASR ASR |
$23.75
|
| Rate for Payer: BCBS Trust/PPO |
$18.98
|
| Rate for Payer: BCN Commercial |
$18.98
|
| Rate for Payer: Cash Price |
$19.58
|
| Rate for Payer: Cofinity Commercial |
$23.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.58
|
| Rate for Payer: Healthscope Commercial |
$24.48
|
| Rate for Payer: Healthscope Whirlpool |
$23.75
|
| Rate for Payer: Mclaren Commercial |
$22.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$20.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$21.54
|
|
|
HC INFLUENZA VIRUS VAC, TRIVALENT (IIV3), SPLIT VIRUS PF, 0.5 ML IM
|
Facility
|
OP
|
$24.48
|
|
|
Service Code
|
CPT 90656
|
| Hospital Charge Code |
63600072
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.79 |
| Max. Negotiated Rate |
$24.48 |
| Rate for Payer: Aetna Commercial |
$22.03
|
| Rate for Payer: ASR ASR |
$23.75
|
| Rate for Payer: BCBS Complete |
$9.79
|
| Rate for Payer: BCBS Trust/PPO |
$18.98
|
| Rate for Payer: BCN Commercial |
$18.98
|
| Rate for Payer: Cash Price |
$19.58
|
| Rate for Payer: Cofinity Commercial |
$23.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.58
|
| Rate for Payer: Healthscope Commercial |
$24.48
|
| Rate for Payer: Healthscope Whirlpool |
$23.75
|
| Rate for Payer: Mclaren Commercial |
$22.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$20.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.14
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$22.28
|
| Rate for Payer: Priority Health Narrow Network |
$17.38
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$21.54
|
|
|
HC INF PUMP PROGRAMMABLE LVL 6
|
Facility
|
OP
|
$690.00
|
|
|
Service Code
|
HCPCS C1772
|
| Hospital Charge Code |
27800141
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$276.00 |
| Max. Negotiated Rate |
$690.00 |
| Rate for Payer: Aetna Commercial |
$621.00
|
| Rate for Payer: ASR ASR |
$669.30
|
| Rate for Payer: BCBS Complete |
$276.00
|
| Rate for Payer: BCBS Trust/PPO |
$534.96
|
| Rate for Payer: BCN Commercial |
$534.96
|
| Rate for Payer: Cash Price |
$552.00
|
| Rate for Payer: Cofinity Commercial |
$648.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$552.00
|
| Rate for Payer: Healthscope Commercial |
$690.00
|
| Rate for Payer: Healthscope Whirlpool |
$669.30
|
| Rate for Payer: Mclaren Commercial |
$621.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$586.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$483.00
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$627.90
|
| Rate for Payer: Priority Health Narrow Network |
$489.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$607.20
|
|
|
HC INF PUMP PROGRAMMABLE LVL 6
|
Facility
|
IP
|
$690.00
|
|
|
Service Code
|
HCPCS C1772
|
| Hospital Charge Code |
27800141
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$483.00 |
| Max. Negotiated Rate |
$690.00 |
| Rate for Payer: Aetna Commercial |
$621.00
|
| Rate for Payer: ASR ASR |
$669.30
|
| Rate for Payer: BCBS Trust/PPO |
$534.96
|
| Rate for Payer: BCN Commercial |
$534.96
|
| Rate for Payer: Cash Price |
$552.00
|
| Rate for Payer: Cofinity Commercial |
$648.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$552.00
|
| Rate for Payer: Healthscope Commercial |
$690.00
|
| Rate for Payer: Healthscope Whirlpool |
$669.30
|
| Rate for Payer: Mclaren Commercial |
$621.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$586.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$483.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$607.20
|
|
|
HC INFRARED THERAPY
|
Facility
|
IP
|
$57.48
|
|
|
Service Code
|
CPT 97026
|
| Hospital Charge Code |
42000013
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$40.24 |
| Max. Negotiated Rate |
$57.48 |
| Rate for Payer: Aetna Commercial |
$51.73
|
| Rate for Payer: ASR ASR |
$55.76
|
| Rate for Payer: BCBS Trust/PPO |
$44.56
|
| Rate for Payer: BCN Commercial |
$44.56
|
| Rate for Payer: Cash Price |
$45.98
|
| Rate for Payer: Cofinity Commercial |
$54.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$45.98
|
| Rate for Payer: Healthscope Commercial |
$57.48
|
| Rate for Payer: Healthscope Whirlpool |
$55.76
|
| Rate for Payer: Mclaren Commercial |
$51.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$48.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$40.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$50.58
|
|
