|
HC DGTZ GLS MCRSCP MPHMTRC ALYS
|
Facility
|
IP
|
$18.72
|
|
|
Service Code
|
CPT 0763T
|
| Hospital Charge Code |
31200021
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$12.17 |
| Max. Negotiated Rate |
$18.72 |
| Rate for Payer: Aetna Commercial |
$16.85
|
| Rate for Payer: ASR ASR |
$18.16
|
| Rate for Payer: ASR Commercial |
$18.16
|
| Rate for Payer: BCBS Trust/PPO |
$15.25
|
| Rate for Payer: BCN Commercial |
$14.51
|
| Rate for Payer: Cash Price |
$14.98
|
| Rate for Payer: Cofinity Commercial |
$17.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.98
|
| Rate for Payer: Healthscope Commercial |
$18.72
|
| Rate for Payer: Healthscope Whirlpool |
$18.16
|
| Rate for Payer: Mclaren Commercial |
$16.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.91
|
| Rate for Payer: Nomi Health Commercial |
$15.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.47
|
|
|
HC DGTZ GLS MCRSCP MPHMTRC ALYS
|
Facility
|
OP
|
$18.72
|
|
|
Service Code
|
CPT 0763T
|
| Hospital Charge Code |
31200021
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$7.49 |
| Max. Negotiated Rate |
$18.72 |
| Rate for Payer: Aetna Commercial |
$16.85
|
| Rate for Payer: Aetna Medicare |
$9.36
|
| Rate for Payer: ASR ASR |
$18.16
|
| Rate for Payer: ASR Commercial |
$18.16
|
| Rate for Payer: BCBS Complete |
$7.49
|
| Rate for Payer: BCBS Trust/PPO |
$15.33
|
| Rate for Payer: BCN Commercial |
$14.51
|
| Rate for Payer: Cash Price |
$14.98
|
| Rate for Payer: Cofinity Commercial |
$17.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.98
|
| Rate for Payer: Healthscope Commercial |
$18.72
|
| Rate for Payer: Healthscope Whirlpool |
$18.16
|
| Rate for Payer: Mclaren Commercial |
$16.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.91
|
| Rate for Payer: Nomi Health Commercial |
$15.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.17
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$16.40
|
| Rate for Payer: Priority Health Narrow Network |
$13.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.47
|
|
|
HC DGTZ GLS MCRSCP SLD LEVEL II
|
Facility
|
IP
|
$18.72
|
|
|
Service Code
|
CPT 0751T
|
| Hospital Charge Code |
31200009
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$12.17 |
| Max. Negotiated Rate |
$18.72 |
| Rate for Payer: Aetna Commercial |
$16.85
|
| Rate for Payer: ASR ASR |
$18.16
|
| Rate for Payer: ASR Commercial |
$18.16
|
| Rate for Payer: BCBS Trust/PPO |
$15.25
|
| Rate for Payer: BCN Commercial |
$14.51
|
| Rate for Payer: Cash Price |
$14.98
|
| Rate for Payer: Cofinity Commercial |
$17.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.98
|
| Rate for Payer: Healthscope Commercial |
$18.72
|
| Rate for Payer: Healthscope Whirlpool |
$18.16
|
| Rate for Payer: Mclaren Commercial |
$16.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.91
|
| Rate for Payer: Nomi Health Commercial |
$15.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.47
|
|
|
HC DGTZ GLS MCRSCP SLD LEVEL II
|
Facility
|
OP
|
$18.72
|
|
|
Service Code
|
CPT 0751T
|
| Hospital Charge Code |
31200009
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$7.49 |
| Max. Negotiated Rate |
$18.72 |
| Rate for Payer: Aetna Commercial |
$16.85
|
| Rate for Payer: Aetna Medicare |
$9.36
|
| Rate for Payer: ASR ASR |
$18.16
|
| Rate for Payer: ASR Commercial |
$18.16
|
| Rate for Payer: BCBS Complete |
$7.49
|
| Rate for Payer: BCBS Trust/PPO |
$15.33
|
| Rate for Payer: BCN Commercial |
$14.51
|
| Rate for Payer: Cash Price |
$14.98
|
| Rate for Payer: Cofinity Commercial |
$17.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.98
|
| Rate for Payer: Healthscope Commercial |
$18.72
|
| Rate for Payer: Healthscope Whirlpool |
$18.16
|
| Rate for Payer: Mclaren Commercial |
$16.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.91
|
| Rate for Payer: Nomi Health Commercial |
$15.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.17
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$16.40
|
| Rate for Payer: Priority Health Narrow Network |
$13.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.47
|
|
|
HC DGTZ GLS MCRSCP SLD LEVEL IV
|
Facility
|
OP
|
$18.72
|
|
|
Service Code
|
CPT 0753T
|
| Hospital Charge Code |
31200011
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$7.49 |
| Max. Negotiated Rate |
$18.72 |
| Rate for Payer: Aetna Commercial |
$16.85
|
| Rate for Payer: Aetna Medicare |
$9.36
|
| Rate for Payer: ASR ASR |
$18.16
|
| Rate for Payer: ASR Commercial |
$18.16
|
| Rate for Payer: BCBS Complete |
$7.49
|
| Rate for Payer: BCBS Trust/PPO |
$15.33
|
| Rate for Payer: BCN Commercial |
$14.51
|
| Rate for Payer: Cash Price |
$14.98
|
| Rate for Payer: Cofinity Commercial |
$17.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.98
|
| Rate for Payer: Healthscope Commercial |
$18.72
|
| Rate for Payer: Healthscope Whirlpool |
$18.16
|
| Rate for Payer: Mclaren Commercial |
$16.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.91
|
| Rate for Payer: Nomi Health Commercial |
$15.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.17
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$16.40
|
| Rate for Payer: Priority Health Narrow Network |
$13.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.47
|
|
|
HC DGTZ GLS MCRSCP SLD LEVEL IV
|
Facility
|
IP
|
$18.72
|
|
|
Service Code
|
CPT 0753T
|
| Hospital Charge Code |
31200011
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$12.17 |
| Max. Negotiated Rate |
$18.72 |
| Rate for Payer: Aetna Commercial |
$16.85
|
| Rate for Payer: ASR ASR |
$18.16
|
| Rate for Payer: ASR Commercial |
$18.16
|
| Rate for Payer: BCBS Trust/PPO |
$15.25
|
| Rate for Payer: BCN Commercial |
$14.51
|
| Rate for Payer: Cash Price |
$14.98
|
| Rate for Payer: Cofinity Commercial |
$17.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.98
|
| Rate for Payer: Healthscope Commercial |
$18.72
|
| Rate for Payer: Healthscope Whirlpool |
$18.16
|
| Rate for Payer: Mclaren Commercial |
$16.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.91
|
| Rate for Payer: Nomi Health Commercial |
$15.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.47
|
|
|
HC DGTZ GLS MCRSCP SLD LEVEL V
|
Facility
|
IP
|
$37.41
|
|
|
Service Code
|
CPT 0754T
|
| Hospital Charge Code |
31200012
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$24.32 |
| Max. Negotiated Rate |
$37.41 |
| Rate for Payer: Aetna Commercial |
$33.67
|
| Rate for Payer: ASR ASR |
$36.29
|
| Rate for Payer: ASR Commercial |
$36.29
|
| Rate for Payer: BCBS Trust/PPO |
$30.49
|
| Rate for Payer: BCN Commercial |
$29.00
|
| Rate for Payer: Cash Price |
$29.93
|
| Rate for Payer: Cofinity Commercial |
$35.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$29.93
|
| Rate for Payer: Healthscope Commercial |
$37.41
|
| Rate for Payer: Healthscope Whirlpool |
$36.29
|
| Rate for Payer: Mclaren Commercial |
$33.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$31.80
|
| Rate for Payer: Nomi Health Commercial |
$30.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$32.92
|
|
|
HC DGTZ GLS MCRSCP SLD LEVEL V
|
Facility
|
OP
|
$37.41
|
|
|
Service Code
|
CPT 0754T
|
| Hospital Charge Code |
31200012
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$14.96 |
| Max. Negotiated Rate |
$37.41 |
| Rate for Payer: Aetna Commercial |
$33.67
|
| Rate for Payer: Aetna Medicare |
$18.70
|
| Rate for Payer: ASR ASR |
$36.29
|
| Rate for Payer: ASR Commercial |
$36.29
|
| Rate for Payer: BCBS Complete |
$14.96
|
| Rate for Payer: BCBS Trust/PPO |
$30.64
|
| Rate for Payer: BCN Commercial |
$29.00
|
| Rate for Payer: Cash Price |
$29.93
|
| Rate for Payer: Cofinity Commercial |
$35.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$29.93
|
| Rate for Payer: Healthscope Commercial |
$37.41
|
| Rate for Payer: Healthscope Whirlpool |
$36.29
|
| Rate for Payer: Mclaren Commercial |
$33.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$31.80
|
| Rate for Payer: Nomi Health Commercial |
$30.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.32
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$32.78
|
| Rate for Payer: Priority Health Narrow Network |
$26.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$32.92
|
|
|
HC DGTZ GLS MCRSCP SLD LEVEL VI
|
Facility
|
OP
|
$37.41
|
|
|
Service Code
|
CPT 0755T
|
| Hospital Charge Code |
31200013
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$14.96 |
| Max. Negotiated Rate |
$37.41 |
| Rate for Payer: Aetna Commercial |
$33.67
|
| Rate for Payer: Aetna Medicare |
$18.70
|
| Rate for Payer: ASR ASR |
$36.29
|
| Rate for Payer: ASR Commercial |
$36.29
|
| Rate for Payer: BCBS Complete |
$14.96
|
| Rate for Payer: BCBS Trust/PPO |
$30.64
|
| Rate for Payer: BCN Commercial |
$29.00
|
| Rate for Payer: Cash Price |
$29.93
|
| Rate for Payer: Cofinity Commercial |
$35.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$29.93
|
| Rate for Payer: Healthscope Commercial |
$37.41
|
| Rate for Payer: Healthscope Whirlpool |
$36.29
|
| Rate for Payer: Mclaren Commercial |
$33.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$31.80
|
| Rate for Payer: Nomi Health Commercial |
$30.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.32
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$32.78
|
| Rate for Payer: Priority Health Narrow Network |
$26.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$32.92
|
|
|
HC DGTZ GLS MCRSCP SLD LEVEL VI
|
Facility
|
IP
|
$37.41
|
|
|
Service Code
|
CPT 0755T
|
| Hospital Charge Code |
31200013
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$24.32 |
| Max. Negotiated Rate |
$37.41 |
| Rate for Payer: Aetna Commercial |
$33.67
|
| Rate for Payer: ASR ASR |
$36.29
|
| Rate for Payer: ASR Commercial |
$36.29
|
| Rate for Payer: BCBS Trust/PPO |
$30.49
|
| Rate for Payer: BCN Commercial |
$29.00
|
| Rate for Payer: Cash Price |
$29.93
|
| Rate for Payer: Cofinity Commercial |
$35.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$29.93
|
| Rate for Payer: Healthscope Commercial |
$37.41
|
| Rate for Payer: Healthscope Whirlpool |
$36.29
|
| Rate for Payer: Mclaren Commercial |
$33.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$31.80
|
| Rate for Payer: Nomi Health Commercial |
$30.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$32.92
|
|
|
HC DGTZ GLS MCRSCP SLD LVL III
|
Facility
|
OP
|
$18.72
|
|
|
Service Code
|
CPT 0752T
|
| Hospital Charge Code |
31200010
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$7.49 |
| Max. Negotiated Rate |
$18.72 |
| Rate for Payer: Aetna Commercial |
$16.85
|
| Rate for Payer: Aetna Medicare |
$9.36
|
| Rate for Payer: ASR ASR |
$18.16
|
| Rate for Payer: ASR Commercial |
$18.16
|
| Rate for Payer: BCBS Complete |
$7.49
|
| Rate for Payer: BCBS Trust/PPO |
$15.33
|
| Rate for Payer: BCN Commercial |
$14.51
|
| Rate for Payer: Cash Price |
$14.98
|
| Rate for Payer: Cofinity Commercial |
$17.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.98
|
| Rate for Payer: Healthscope Commercial |
$18.72
|
| Rate for Payer: Healthscope Whirlpool |
$18.16
|
| Rate for Payer: Mclaren Commercial |
$16.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.91
|
| Rate for Payer: Nomi Health Commercial |
$15.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.17
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$16.40
|
| Rate for Payer: Priority Health Narrow Network |
$13.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.47
|
|
|
HC DGTZ GLS MCRSCP SLD LVL III
|
Facility
|
IP
|
$18.72
|
|
|
Service Code
|
CPT 0752T
|
| Hospital Charge Code |
31200010
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$12.17 |
| Max. Negotiated Rate |
$18.72 |
| Rate for Payer: Aetna Commercial |
$16.85
|
| Rate for Payer: ASR ASR |
$18.16
|
| Rate for Payer: ASR Commercial |
$18.16
|
| Rate for Payer: BCBS Trust/PPO |
$15.25
|
| Rate for Payer: BCN Commercial |
$14.51
|
| Rate for Payer: Cash Price |
$14.98
|
| Rate for Payer: Cofinity Commercial |
$17.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.98
|
| Rate for Payer: Healthscope Commercial |
$18.72
|
| Rate for Payer: Healthscope Whirlpool |
$18.16
|
| Rate for Payer: Mclaren Commercial |
$16.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.91
|
| Rate for Payer: Nomi Health Commercial |
$15.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.47
|
|
|
HC DGTZ GLS MCRSCP SLD SPC GRPI
|
Facility
|
IP
|
$18.72
|
|
|
Service Code
|
CPT 0756T
|
| Hospital Charge Code |
31200014
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$12.17 |
| Max. Negotiated Rate |
$18.72 |
| Rate for Payer: Aetna Commercial |
$16.85
|
| Rate for Payer: ASR ASR |
$18.16
|
| Rate for Payer: ASR Commercial |
$18.16
|
| Rate for Payer: BCBS Trust/PPO |
$15.25
|
| Rate for Payer: BCN Commercial |
$14.51
|
| Rate for Payer: Cash Price |
$14.98
|
| Rate for Payer: Cofinity Commercial |
$17.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.98
|
| Rate for Payer: Healthscope Commercial |
$18.72
|
| Rate for Payer: Healthscope Whirlpool |
$18.16
|
| Rate for Payer: Mclaren Commercial |
$16.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.91
|
| Rate for Payer: Nomi Health Commercial |
$15.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.47
|
|
|
HC DGTZ GLS MCRSCP SLD SPC GRPI
|
Facility
|
OP
|
$18.72
|
|
|
Service Code
|
CPT 0756T
|
| Hospital Charge Code |
31200014
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$7.49 |
| Max. Negotiated Rate |
$18.72 |
| Rate for Payer: Aetna Commercial |
$16.85
|
| Rate for Payer: Aetna Medicare |
$9.36
|
| Rate for Payer: ASR ASR |
$18.16
|
| Rate for Payer: ASR Commercial |
$18.16
|
| Rate for Payer: BCBS Complete |
$7.49
|
| Rate for Payer: BCBS Trust/PPO |
$15.33
|
| Rate for Payer: BCN Commercial |
$14.51
|
| Rate for Payer: Cash Price |
$14.98
|
| Rate for Payer: Cofinity Commercial |
$17.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.98
|
| Rate for Payer: Healthscope Commercial |
$18.72
|
| Rate for Payer: Healthscope Whirlpool |
$18.16
|
| Rate for Payer: Mclaren Commercial |
$16.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.91
|
| Rate for Payer: Nomi Health Commercial |
$15.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.17
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$16.40
|
| Rate for Payer: Priority Health Narrow Network |
$13.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.47
|
|
|
HC DGTZ GLS MCRSCP SL IMM 1ST
|
Facility
|
OP
|
$18.72
|
|
|
Service Code
|
CPT 0760T
|
| Hospital Charge Code |
31200018
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$7.49 |
| Max. Negotiated Rate |
$18.72 |
| Rate for Payer: Aetna Commercial |
$16.85
|
| Rate for Payer: Aetna Medicare |
$9.36
|
| Rate for Payer: ASR ASR |
$18.16
|
| Rate for Payer: ASR Commercial |
$18.16
|
| Rate for Payer: BCBS Complete |
$7.49
|
| Rate for Payer: BCBS Trust/PPO |
$15.33
|
| Rate for Payer: BCN Commercial |
$14.51
|
| Rate for Payer: Cash Price |
$14.98
|
| Rate for Payer: Cofinity Commercial |
$17.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.98
|
| Rate for Payer: Healthscope Commercial |
$18.72
|
| Rate for Payer: Healthscope Whirlpool |
$18.16
|
| Rate for Payer: Mclaren Commercial |
$16.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.91
|
| Rate for Payer: Nomi Health Commercial |
$15.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.17
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$16.40
|
| Rate for Payer: Priority Health Narrow Network |
$13.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.47
|
|
|
HC DGTZ GLS MCRSCP SL IMM 1ST
|
Facility
|
IP
|
$18.72
|
|
|
Service Code
|
CPT 0760T
|
| Hospital Charge Code |
31200018
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$12.17 |
| Max. Negotiated Rate |
$18.72 |
| Rate for Payer: Aetna Commercial |
$16.85
|
| Rate for Payer: ASR ASR |
$18.16
|
| Rate for Payer: ASR Commercial |
$18.16
|
| Rate for Payer: BCBS Trust/PPO |
$15.25
|
| Rate for Payer: BCN Commercial |
$14.51
|
| Rate for Payer: Cash Price |
$14.98
|
| Rate for Payer: Cofinity Commercial |
$17.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.98
|
| Rate for Payer: Healthscope Commercial |
$18.72
|
| Rate for Payer: Healthscope Whirlpool |
$18.16
|
| Rate for Payer: Mclaren Commercial |
$16.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.91
|
| Rate for Payer: Nomi Health Commercial |
$15.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.47
|
|
|
HC DGTZ GLS MCRSCP SL IMM EA 1
|
Facility
|
OP
|
$18.72
|
|
|
Service Code
|
CPT 0761T
|
| Hospital Charge Code |
31200019
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$7.49 |
| Max. Negotiated Rate |
$18.72 |
| Rate for Payer: Aetna Commercial |
$16.85
|
| Rate for Payer: Aetna Medicare |
$9.36
|
| Rate for Payer: ASR ASR |
$18.16
|
| Rate for Payer: ASR Commercial |
$18.16
|
| Rate for Payer: BCBS Complete |
$7.49
|
| Rate for Payer: BCBS Trust/PPO |
$15.33
|
| Rate for Payer: BCN Commercial |
$14.51
|
| Rate for Payer: Cash Price |
$14.98
|
| Rate for Payer: Cofinity Commercial |
$17.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.98
|
| Rate for Payer: Healthscope Commercial |
$18.72
|
| Rate for Payer: Healthscope Whirlpool |
$18.16
|
| Rate for Payer: Mclaren Commercial |
$16.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.91
|
| Rate for Payer: Nomi Health Commercial |
$15.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.17
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$16.40
|
| Rate for Payer: Priority Health Narrow Network |
$13.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.47
|
|
|
HC DGTZ GLS MCRSCP SL IMM EA 1
|
Facility
|
IP
|
$18.72
|
|
|
Service Code
|
CPT 0761T
|
| Hospital Charge Code |
31200019
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$12.17 |
| Max. Negotiated Rate |
$18.72 |
| Rate for Payer: Aetna Commercial |
$16.85
|
| Rate for Payer: ASR ASR |
$18.16
|
| Rate for Payer: ASR Commercial |
$18.16
|
| Rate for Payer: BCBS Trust/PPO |
$15.25
|
| Rate for Payer: BCN Commercial |
$14.51
|
| Rate for Payer: Cash Price |
$14.98
|
| Rate for Payer: Cofinity Commercial |
$17.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.98
|
| Rate for Payer: Healthscope Commercial |
$18.72
|
| Rate for Payer: Healthscope Whirlpool |
$18.16
|
| Rate for Payer: Mclaren Commercial |
$16.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.91
|
| Rate for Payer: Nomi Health Commercial |
$15.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.47
|
|
|
HC DGTZ GLS MCRSCP SL IMM EA M
|
Facility
|
IP
|
$18.72
|
|
|
Service Code
|
CPT 0762T
|
| Hospital Charge Code |
31200020
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$12.17 |
| Max. Negotiated Rate |
$18.72 |
| Rate for Payer: Aetna Commercial |
$16.85
|
| Rate for Payer: ASR ASR |
$18.16
|
| Rate for Payer: ASR Commercial |
$18.16
|
| Rate for Payer: BCBS Trust/PPO |
$15.25
|
| Rate for Payer: BCN Commercial |
$14.51
|
| Rate for Payer: Cash Price |
$14.98
|
| Rate for Payer: Cofinity Commercial |
$17.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.98
|
| Rate for Payer: Healthscope Commercial |
$18.72
|
| Rate for Payer: Healthscope Whirlpool |
$18.16
|
| Rate for Payer: Mclaren Commercial |
$16.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.91
|
| Rate for Payer: Nomi Health Commercial |
$15.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.47
|
|
|
HC DGTZ GLS MCRSCP SL IMM EA M
|
Facility
|
OP
|
$18.72
|
|
|
Service Code
|
CPT 0762T
|
| Hospital Charge Code |
31200020
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$7.49 |
| Max. Negotiated Rate |
$18.72 |
| Rate for Payer: Aetna Commercial |
$16.85
|
| Rate for Payer: Aetna Medicare |
$9.36
|
| Rate for Payer: ASR ASR |
$18.16
|
| Rate for Payer: ASR Commercial |
$18.16
|
| Rate for Payer: BCBS Complete |
$7.49
|
| Rate for Payer: BCBS Trust/PPO |
$15.33
|
| Rate for Payer: BCN Commercial |
$14.51
|
| Rate for Payer: Cash Price |
$14.98
|
| Rate for Payer: Cofinity Commercial |
$17.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.98
|
| Rate for Payer: Healthscope Commercial |
$18.72
|
| Rate for Payer: Healthscope Whirlpool |
$18.16
|
| Rate for Payer: Mclaren Commercial |
$16.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.91
|
| Rate for Payer: Nomi Health Commercial |
$15.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.17
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$16.40
|
| Rate for Payer: Priority Health Narrow Network |
$13.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.47
|
|
|
HC DGTZ GLS MCRSCP SL SPC GRPII
|
Facility
|
OP
|
$18.72
|
|
|
Service Code
|
CPT 0757T
|
| Hospital Charge Code |
31200015
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$7.49 |
| Max. Negotiated Rate |
$18.72 |
| Rate for Payer: Aetna Commercial |
$16.85
|
| Rate for Payer: Aetna Medicare |
$9.36
|
| Rate for Payer: ASR ASR |
$18.16
|
| Rate for Payer: ASR Commercial |
$18.16
|
| Rate for Payer: BCBS Complete |
$7.49
|
| Rate for Payer: BCBS Trust/PPO |
$15.33
|
| Rate for Payer: BCN Commercial |
$14.51
|
| Rate for Payer: Cash Price |
$14.98
|
| Rate for Payer: Cofinity Commercial |
$17.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.98
|
| Rate for Payer: Healthscope Commercial |
$18.72
|
| Rate for Payer: Healthscope Whirlpool |
$18.16
|
| Rate for Payer: Mclaren Commercial |
$16.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.91
|
| Rate for Payer: Nomi Health Commercial |
$15.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.17
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$16.40
|
| Rate for Payer: Priority Health Narrow Network |
$13.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.47
|
|
|
HC DGTZ GLS MCRSCP SL SPC GRPII
|
Facility
|
IP
|
$18.72
|
|
|
Service Code
|
CPT 0757T
|
| Hospital Charge Code |
31200015
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$12.17 |
| Max. Negotiated Rate |
$18.72 |
| Rate for Payer: Aetna Commercial |
$16.85
|
| Rate for Payer: ASR ASR |
$18.16
|
| Rate for Payer: ASR Commercial |
$18.16
|
| Rate for Payer: BCBS Trust/PPO |
$15.25
|
| Rate for Payer: BCN Commercial |
$14.51
|
| Rate for Payer: Cash Price |
$14.98
|
| Rate for Payer: Cofinity Commercial |
$17.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.98
|
| Rate for Payer: Healthscope Commercial |
$18.72
|
| Rate for Payer: Healthscope Whirlpool |
$18.16
|
| Rate for Payer: Mclaren Commercial |
$16.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.91
|
| Rate for Payer: Nomi Health Commercial |
$15.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.47
|
|
|
HC DGTZ GLS MCRSCP SL SPC HCHEM
|
Facility
|
IP
|
$18.72
|
|
|
Service Code
|
CPT 0758T
|
| Hospital Charge Code |
31200016
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$12.17 |
| Max. Negotiated Rate |
$18.72 |
| Rate for Payer: Aetna Commercial |
$16.85
|
| Rate for Payer: ASR ASR |
$18.16
|
| Rate for Payer: ASR Commercial |
$18.16
|
| Rate for Payer: BCBS Trust/PPO |
$15.25
|
| Rate for Payer: BCN Commercial |
$14.51
|
| Rate for Payer: Cash Price |
$14.98
|
| Rate for Payer: Cofinity Commercial |
$17.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.98
|
| Rate for Payer: Healthscope Commercial |
$18.72
|
| Rate for Payer: Healthscope Whirlpool |
$18.16
|
| Rate for Payer: Mclaren Commercial |
$16.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.91
|
| Rate for Payer: Nomi Health Commercial |
$15.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.47
|
|
|
HC DGTZ GLS MCRSCP SL SPC HCHEM
|
Facility
|
OP
|
$18.72
|
|
|
Service Code
|
CPT 0758T
|
| Hospital Charge Code |
31200016
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$7.49 |
| Max. Negotiated Rate |
$18.72 |
| Rate for Payer: Aetna Commercial |
$16.85
|
| Rate for Payer: Aetna Medicare |
$9.36
|
| Rate for Payer: ASR ASR |
$18.16
|
| Rate for Payer: ASR Commercial |
$18.16
|
| Rate for Payer: BCBS Complete |
$7.49
|
| Rate for Payer: BCBS Trust/PPO |
$15.33
|
| Rate for Payer: BCN Commercial |
$14.51
|
| Rate for Payer: Cash Price |
$14.98
|
| Rate for Payer: Cofinity Commercial |
$17.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.98
|
| Rate for Payer: Healthscope Commercial |
$18.72
|
| Rate for Payer: Healthscope Whirlpool |
$18.16
|
| Rate for Payer: Mclaren Commercial |
$16.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.91
|
| Rate for Payer: Nomi Health Commercial |
$15.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.17
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$16.40
|
| Rate for Payer: Priority Health Narrow Network |
$13.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.47
|
|
|
HC DGTZ GLS MCRSCP SL SP GRPIII
|
Facility
|
IP
|
$18.72
|
|
|
Service Code
|
CPT 0759T
|
| Hospital Charge Code |
31200017
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$12.17 |
| Max. Negotiated Rate |
$18.72 |
| Rate for Payer: Aetna Commercial |
$16.85
|
| Rate for Payer: ASR ASR |
$18.16
|
| Rate for Payer: ASR Commercial |
$18.16
|
| Rate for Payer: BCBS Trust/PPO |
$15.25
|
| Rate for Payer: BCN Commercial |
$14.51
|
| Rate for Payer: Cash Price |
$14.98
|
| Rate for Payer: Cofinity Commercial |
$17.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.98
|
| Rate for Payer: Healthscope Commercial |
$18.72
|
| Rate for Payer: Healthscope Whirlpool |
$18.16
|
| Rate for Payer: Mclaren Commercial |
$16.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.91
|
| Rate for Payer: Nomi Health Commercial |
$15.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.47
|
|
