|
HC NON THROMBOLYTIC INTRACRANIAL INITIAL VASCULAR TERRITORY
|
Facility
|
IP
|
$4,427.92
|
|
|
Service Code
|
CPT 61650
|
| Hospital Charge Code |
36100514
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$3,099.54 |
| Max. Negotiated Rate |
$4,427.92 |
| Rate for Payer: Aetna Commercial |
$3,985.13
|
| Rate for Payer: ASR ASR |
$4,295.08
|
| Rate for Payer: BCBS Trust/PPO |
$3,432.97
|
| Rate for Payer: BCN Commercial |
$3,432.97
|
| Rate for Payer: Cash Price |
$3,542.34
|
| Rate for Payer: Cofinity Commercial |
$4,162.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,542.34
|
| Rate for Payer: Healthscope Commercial |
$4,427.92
|
| Rate for Payer: Healthscope Whirlpool |
$4,295.08
|
| Rate for Payer: Mclaren Commercial |
$3,985.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3,763.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,099.54
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3,896.57
|
|
|
HC NORCLOZAPINE LEVEL
|
Facility
|
IP
|
$24.48
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
30100065
|
|
Hospital Revenue Code
|
301
|
| 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 NORCLOZAPINE LEVEL
|
Facility
|
OP
|
$24.48
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
30100065
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$10.20 |
| Max. Negotiated Rate |
$229.87 |
| Rate for Payer: Aetna Commercial |
$22.03
|
| Rate for Payer: Aetna Medicare |
$18.64
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$23.30
|
| Rate for Payer: Amish Plain Church Group Commercial |
$23.30
|
| Rate for Payer: ASR ASR |
$23.75
|
| Rate for Payer: BCBS Complete |
$10.71
|
| Rate for Payer: BCBS MAPPO |
$18.64
|
| Rate for Payer: BCBS Trust/PPO |
$18.98
|
| Rate for Payer: BCN Commercial |
$18.98
|
| Rate for Payer: BCN Medicare Advantage |
$18.64
|
| Rate for Payer: Cash Price |
$19.58
|
| 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: Health Alliance Plan Medicare Advantage |
$18.64
|
| Rate for Payer: Healthscope Commercial |
$24.48
|
| Rate for Payer: Healthscope Whirlpool |
$23.75
|
| Rate for Payer: Humana Choice PPO Medicare |
$18.64
|
| Rate for Payer: Mclaren Commercial |
$22.03
|
| Rate for Payer: Mclaren Medicaid |
$10.20
|
| Rate for Payer: Mclaren Medicare |
$18.64
|
| Rate for Payer: Meridian Medicaid |
$10.71
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$19.57
|
| Rate for Payer: MI Amish Medical Board Commercial |
$21.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$20.81
|
| Rate for Payer: PACE Medicare |
$17.71
|
| Rate for Payer: PACE SWMI |
$18.64
|
| Rate for Payer: PHP Commercial |
$20.50
|
| Rate for Payer: PHP Medicaid |
$10.20
|
| Rate for Payer: PHP Medicare Advantage |
$18.64
|
| Rate for Payer: Priority Health Choice Medicaid |
$10.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.14
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$229.87
|
| Rate for Payer: Priority Health Medicare |
$18.64
|
| Rate for Payer: Priority Health Narrow Network |
$183.90
|
| Rate for Payer: Railroad Medicare Medicare |
$18.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$21.54
|
| Rate for Payer: UHC Medicare Advantage |
$19.20
|
| Rate for Payer: VA VA |
$18.64
|
|
|
HC NORTRIPTYLINE LVL
|
Facility
|
IP
|
$43.00
|
|
|
Service Code
|
CPT 80335
|
| Hospital Charge Code |
30100592
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$30.10 |
| Max. Negotiated Rate |
$43.00 |
| Rate for Payer: Aetna Commercial |
$38.70
|
| Rate for Payer: ASR ASR |
$41.71
|
| Rate for Payer: BCBS Trust/PPO |
$33.34
|
| Rate for Payer: BCN Commercial |
$33.34
|
| Rate for Payer: Cash Price |
$34.40
|
| Rate for Payer: Cofinity Commercial |
$40.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$34.40
|
| Rate for Payer: Healthscope Commercial |
$43.00
|
| Rate for Payer: Healthscope Whirlpool |
$41.71
|
| Rate for Payer: Mclaren Commercial |
$38.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$36.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$30.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$37.84
|
|
|
HC NORTRIPTYLINE LVL
|
Facility
|
OP
|
$43.00
|
|
|
Service Code
|
CPT 80335
|
| Hospital Charge Code |
30100592
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$17.20 |
| Max. Negotiated Rate |
$43.00 |
| Rate for Payer: Aetna Commercial |
$38.70
|
| Rate for Payer: ASR ASR |
$41.71
|
| Rate for Payer: BCBS Complete |
$17.20
|
| Rate for Payer: BCBS Trust/PPO |
$33.34
|
| Rate for Payer: BCN Commercial |
$33.34
|
| Rate for Payer: Cash Price |
$34.40
|
| Rate for Payer: Cofinity Commercial |
$40.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$34.40
|
| Rate for Payer: Healthscope Commercial |
$43.00
|
| Rate for Payer: Healthscope Whirlpool |
$41.71
|
| Rate for Payer: Mclaren Commercial |
$38.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$36.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$30.10
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$39.13
|
| Rate for Payer: Priority Health Narrow Network |
$30.53
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$37.84
|
|
|
HC NOSEBLEED/ENT
|
Facility
|
IP
|
$406.40
|
|
| Hospital Charge Code |
45000061
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$284.48 |
| Max. Negotiated Rate |
$406.40 |
| Rate for Payer: Aetna Commercial |
$365.76
|
| Rate for Payer: ASR ASR |
$394.21
|
| Rate for Payer: BCBS Trust/PPO |
$315.08
|
| Rate for Payer: BCN Commercial |
$315.08
|
| Rate for Payer: Cash Price |
$325.12
|
| Rate for Payer: Cofinity Commercial |
$382.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$325.12
|
| Rate for Payer: Healthscope Commercial |
$406.40
|
| Rate for Payer: Healthscope Whirlpool |
$394.21
|
| Rate for Payer: Mclaren Commercial |
$365.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$345.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$284.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$357.63
|
|
|
HC NOSEBLEED/ENT
|
Facility
|
OP
|
$406.40
|
|
| Hospital Charge Code |
45000061
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$162.56 |
| Max. Negotiated Rate |
$406.40 |
| Rate for Payer: Aetna Commercial |
$365.76
|
| Rate for Payer: ASR ASR |
$394.21
|
| Rate for Payer: BCBS Complete |
$162.56
|
| Rate for Payer: BCBS Trust/PPO |
$315.08
|
| Rate for Payer: BCN Commercial |
$315.08
|
| Rate for Payer: Cash Price |
$325.12
|
| Rate for Payer: Cofinity Commercial |
$382.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$325.12
|
| Rate for Payer: Healthscope Commercial |
$406.40
|
| Rate for Payer: Healthscope Whirlpool |
$394.21
|
| Rate for Payer: Mclaren Commercial |
$365.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$345.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$284.48
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$369.82
|
| Rate for Payer: Priority Health Narrow Network |
$288.54
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$357.63
|
|
|
HC NUC MED STRESS TEST
|
Facility
|
IP
|
$929.67
|
|
|
Service Code
|
CPT 93017
|
| Hospital Charge Code |
48200005
|
|
Hospital Revenue Code
|
482
|
| Min. Negotiated Rate |
$650.77 |
| Max. Negotiated Rate |
$929.67 |
| Rate for Payer: Aetna Commercial |
$836.70
|
| Rate for Payer: ASR ASR |
$901.78
|
| Rate for Payer: BCBS Trust/PPO |
$720.77
|
| Rate for Payer: BCN Commercial |
$720.77
|
| Rate for Payer: Cash Price |
$743.74
|
| Rate for Payer: Cofinity Commercial |
$873.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$743.74
|
| Rate for Payer: Healthscope Commercial |
$929.67
|
| Rate for Payer: Healthscope Whirlpool |
$901.78
|
| Rate for Payer: Mclaren Commercial |
$836.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$790.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$650.77
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$818.11
|
|
|
HC NUC MED STRESS TEST
|
Facility
|
OP
|
$929.67
|
|
|
Service Code
|
CPT 93017
|
| Hospital Charge Code |
48200005
|
|
Hospital Revenue Code
|
482
|
| Min. Negotiated Rate |
$152.61 |
| Max. Negotiated Rate |
$929.67 |
| Rate for Payer: Aetna Commercial |
$836.70
|
| Rate for Payer: Aetna Medicare |
$279.00
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$348.75
|
| Rate for Payer: Amish Plain Church Group Commercial |
$348.75
|
| Rate for Payer: ASR ASR |
$901.78
|
| Rate for Payer: BCBS Complete |
$160.26
|
| Rate for Payer: BCBS MAPPO |
$279.00
|
| Rate for Payer: BCBS Trust/PPO |
$720.77
|
| Rate for Payer: BCN Commercial |
$720.77
|
| Rate for Payer: BCN Medicare Advantage |
$279.00
|
| Rate for Payer: Cash Price |
$743.74
|
| Rate for Payer: Cash Price |
$743.74
|
| Rate for Payer: Cofinity Commercial |
$873.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$743.74
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$279.00
|
| Rate for Payer: Healthscope Commercial |
$929.67
|
| Rate for Payer: Healthscope Whirlpool |
$901.78
|
| Rate for Payer: Humana Choice PPO Medicare |
$279.00
|
| Rate for Payer: Mclaren Commercial |
$836.70
|
| Rate for Payer: Mclaren Medicaid |
$152.61
|
| Rate for Payer: Mclaren Medicare |
$279.00
|
| Rate for Payer: Meridian Medicaid |
$160.26
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$292.95
|
| Rate for Payer: MI Amish Medical Board Commercial |
$320.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$790.22
|
| Rate for Payer: PACE Medicare |
$265.05
|
| Rate for Payer: PACE SWMI |
$279.00
|
| Rate for Payer: PHP Commercial |
$306.90
|
| Rate for Payer: PHP Medicaid |
$152.61
|
| Rate for Payer: PHP Medicare Advantage |
$279.00
|
| Rate for Payer: Priority Health Choice Medicaid |
$152.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$650.77
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$849.68
|
| Rate for Payer: Priority Health Medicare |
$279.00
|
| Rate for Payer: Priority Health Narrow Network |
$679.74
|
| Rate for Payer: Railroad Medicare Medicare |
$279.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$818.11
|
| Rate for Payer: UHC Medicare Advantage |
$287.37
|
| Rate for Payer: VA VA |
$279.00
|
|
|
HC NURSEMAID ELBOW REDUCTION
|
Facility
|
OP
|
$211.74
|
|
|
Service Code
|
CPT 24640
|
| Hospital Charge Code |
45000008
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$114.66 |
| Max. Negotiated Rate |
$262.02 |
| Rate for Payer: Aetna Commercial |
$190.57
|
| Rate for Payer: Aetna Medicare |
$209.62
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$262.02
|
| Rate for Payer: Amish Plain Church Group Commercial |
$262.02
|
| Rate for Payer: ASR ASR |
$205.39
|
| Rate for Payer: BCBS Complete |
$120.41
|
| Rate for Payer: BCBS MAPPO |
$209.62
|
| Rate for Payer: BCBS Trust/PPO |
$164.16
|
| Rate for Payer: BCN Commercial |
$164.16
|
| Rate for Payer: BCN Medicare Advantage |
$209.62
|
| Rate for Payer: Cash Price |
$169.39
|
| Rate for Payer: Cash Price |
$169.39
|
| Rate for Payer: Cofinity Commercial |
$199.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$169.39
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$209.62
|
| Rate for Payer: Healthscope Commercial |
$211.74
|
| Rate for Payer: Healthscope Whirlpool |
$205.39
|
| Rate for Payer: Humana Choice PPO Medicare |
$209.62
|
| Rate for Payer: Mclaren Commercial |
$190.57
|
| Rate for Payer: Mclaren Medicaid |
$114.66
|
| Rate for Payer: Mclaren Medicare |
$209.62
|
| Rate for Payer: Meridian Medicaid |
$120.41
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$220.10
|
| Rate for Payer: MI Amish Medical Board Commercial |
$241.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$179.98
|
| Rate for Payer: PACE Medicare |
$199.14
|
| Rate for Payer: PACE SWMI |
$209.62
|
| Rate for Payer: PHP Commercial |
$230.58
|
| Rate for Payer: PHP Medicaid |
$114.66
|
| Rate for Payer: PHP Medicare Advantage |
$209.62
|
| Rate for Payer: Priority Health Choice Medicaid |
$114.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$148.22
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$255.20
|
| Rate for Payer: Priority Health Medicare |
$209.62
|
| Rate for Payer: Priority Health Narrow Network |
$204.16
|
| Rate for Payer: Railroad Medicare Medicare |
$209.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$186.33
|
| Rate for Payer: UHC Medicare Advantage |
$215.91
|
| Rate for Payer: VA VA |
$209.62
|
|
|
HC NURSEMAID ELBOW REDUCTION
|
Facility
|
IP
|
$211.74
|
|
|
Service Code
|
CPT 24640
|
| Hospital Charge Code |
45000008
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$148.22 |
| Max. Negotiated Rate |
$211.74 |
| Rate for Payer: Aetna Commercial |
$190.57
|
| Rate for Payer: ASR ASR |
$205.39
|
| Rate for Payer: BCBS Trust/PPO |
$164.16
|
| Rate for Payer: BCN Commercial |
$164.16
|
| Rate for Payer: Cash Price |
$169.39
|
| Rate for Payer: Cofinity Commercial |
$199.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$169.39
|
| Rate for Payer: Healthscope Commercial |
$211.74
|
| Rate for Payer: Healthscope Whirlpool |
$205.39
|
| Rate for Payer: Mclaren Commercial |
$190.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$179.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$148.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$186.33
|
|
|
HC NUSHIELD (1.6 SQ CM DISC) PER SQ CM
|
Facility
|
OP
|
$604.35
|
|
|
Service Code
|
HCPCS Q4160
|
| Hospital Charge Code |
63600153
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$241.74 |
| Max. Negotiated Rate |
$604.35 |
| Rate for Payer: Aetna Commercial |
$543.92
|
| Rate for Payer: ASR ASR |
$586.22
|
| Rate for Payer: BCBS Complete |
$241.74
|
| Rate for Payer: BCBS Trust/PPO |
$468.55
|
| Rate for Payer: BCN Commercial |
$468.55
|
| Rate for Payer: Cash Price |
$483.48
|
| Rate for Payer: Cofinity Commercial |
$568.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$483.48
|
| Rate for Payer: Healthscope Commercial |
$604.35
|
| Rate for Payer: Healthscope Whirlpool |
$586.22
|
| Rate for Payer: Mclaren Commercial |
$543.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$513.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$423.04
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$549.96
|
| Rate for Payer: Priority Health Narrow Network |
$429.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$531.83
|
|
|
HC NUSHIELD (1.6 SQ CM DISC) PER SQ CM
|
Facility
|
IP
|
$604.35
|
|
|
Service Code
|
HCPCS Q4160
|
| Hospital Charge Code |
63600153
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$423.04 |
| Max. Negotiated Rate |
$604.35 |
| Rate for Payer: Aetna Commercial |
$543.92
|
| Rate for Payer: ASR ASR |
$586.22
|
| Rate for Payer: BCBS Trust/PPO |
$468.55
|
| Rate for Payer: BCN Commercial |
$468.55
|
| Rate for Payer: Cash Price |
$483.48
|
| Rate for Payer: Cofinity Commercial |
$568.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$483.48
|
| Rate for Payer: Healthscope Commercial |
$604.35
|
| Rate for Payer: Healthscope Whirlpool |
$586.22
|
| Rate for Payer: Mclaren Commercial |
$543.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$513.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$423.04
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$531.83
|
|
|
HC NUSHIELD 2X3 PER SQ CM
|
Facility
|
IP
|
$322.52
|
|
|
Service Code
|
HCPCS Q4160
|
| Hospital Charge Code |
63600154
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$225.76 |
| Max. Negotiated Rate |
$322.52 |
| Rate for Payer: Aetna Commercial |
$290.27
|
| Rate for Payer: ASR ASR |
$312.84
|
| Rate for Payer: BCBS Trust/PPO |
$250.05
|
| Rate for Payer: BCN Commercial |
$250.05
|
| Rate for Payer: Cash Price |
$258.02
|
| Rate for Payer: Cofinity Commercial |
$303.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$258.02
|
| Rate for Payer: Healthscope Commercial |
$322.52
|
| Rate for Payer: Healthscope Whirlpool |
$312.84
|
| Rate for Payer: Mclaren Commercial |
$290.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$274.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$225.76
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$283.82
|
|
|
HC NUSHIELD 2X3 PER SQ CM
|
Facility
|
OP
|
$322.52
|
|
|
Service Code
|
HCPCS Q4160
|
| Hospital Charge Code |
63600154
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$129.01 |
| Max. Negotiated Rate |
$322.52 |
| Rate for Payer: Aetna Commercial |
$290.27
|
| Rate for Payer: ASR ASR |
$312.84
|
| Rate for Payer: BCBS Complete |
$129.01
|
| Rate for Payer: BCBS Trust/PPO |
$250.05
|
| Rate for Payer: BCN Commercial |
$250.05
|
| Rate for Payer: Cash Price |
$258.02
|
| Rate for Payer: Cofinity Commercial |
$303.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$258.02
|
| Rate for Payer: Healthscope Commercial |
$322.52
|
| Rate for Payer: Healthscope Whirlpool |
$312.84
|
| Rate for Payer: Mclaren Commercial |
$290.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$274.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$225.76
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$293.49
|
| Rate for Payer: Priority Health Narrow Network |
$228.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$283.82
|
|
|
HC NUSHIELD 2X4 PER SQ CM
|
Facility
|
OP
|
$302.82
|
|
|
Service Code
|
HCPCS Q4160
|
| Hospital Charge Code |
63600175
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$121.13 |
| Max. Negotiated Rate |
$302.82 |
| Rate for Payer: Aetna Commercial |
$272.54
|
| Rate for Payer: ASR ASR |
$293.74
|
| Rate for Payer: BCBS Complete |
$121.13
|
| Rate for Payer: BCBS Trust/PPO |
$234.78
|
| Rate for Payer: BCN Commercial |
$234.78
|
| Rate for Payer: Cash Price |
$242.26
|
| Rate for Payer: Cofinity Commercial |
$284.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$242.26
|
| Rate for Payer: Healthscope Commercial |
$302.82
|
| Rate for Payer: Healthscope Whirlpool |
$293.74
|
| Rate for Payer: Mclaren Commercial |
$272.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$257.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$211.97
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$275.57
|
| Rate for Payer: Priority Health Narrow Network |
$215.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$266.48
|
|
|
HC NUSHIELD 2X4 PER SQ CM
|
Facility
|
IP
|
$302.82
|
|
|
Service Code
|
HCPCS Q4160
|
| Hospital Charge Code |
63600175
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$211.97 |
| Max. Negotiated Rate |
$302.82 |
| Rate for Payer: Aetna Commercial |
$272.54
|
| Rate for Payer: ASR ASR |
$293.74
|
| Rate for Payer: BCBS Trust/PPO |
$234.78
|
| Rate for Payer: BCN Commercial |
$234.78
|
| Rate for Payer: Cash Price |
$242.26
|
| Rate for Payer: Cofinity Commercial |
$284.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$242.26
|
| Rate for Payer: Healthscope Commercial |
$302.82
|
| Rate for Payer: Healthscope Whirlpool |
$293.74
|
| Rate for Payer: Mclaren Commercial |
$272.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$257.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$211.97
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$266.48
|
|
|
HC NUSHIELD 3X4 PER SQ CM
|
Facility
|
OP
|
$292.19
|
|
|
Service Code
|
HCPCS Q4160
|
| Hospital Charge Code |
63600176
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$116.88 |
| Max. Negotiated Rate |
$292.19 |
| Rate for Payer: Aetna Commercial |
$262.97
|
| Rate for Payer: ASR ASR |
$283.42
|
| Rate for Payer: BCBS Complete |
$116.88
|
| Rate for Payer: BCBS Trust/PPO |
$226.53
|
| Rate for Payer: BCN Commercial |
$226.53
|
| Rate for Payer: Cash Price |
$233.75
|
| Rate for Payer: Cofinity Commercial |
$274.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$233.75
|
| Rate for Payer: Healthscope Commercial |
$292.19
|
| Rate for Payer: Healthscope Whirlpool |
$283.42
|
| Rate for Payer: Mclaren Commercial |
$262.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$248.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$204.53
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$265.89
|
| Rate for Payer: Priority Health Narrow Network |
$207.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$257.13
|
|
|
HC NUSHIELD 3X4 PER SQ CM
|
Facility
|
IP
|
$292.19
|
|
|
Service Code
|
HCPCS Q4160
|
| Hospital Charge Code |
63600176
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$204.53 |
| Max. Negotiated Rate |
$292.19 |
| Rate for Payer: Aetna Commercial |
$262.97
|
| Rate for Payer: ASR ASR |
$283.42
|
| Rate for Payer: BCBS Trust/PPO |
$226.53
|
| Rate for Payer: BCN Commercial |
$226.53
|
| Rate for Payer: Cash Price |
$233.75
|
| Rate for Payer: Cofinity Commercial |
$274.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$233.75
|
| Rate for Payer: Healthscope Commercial |
$292.19
|
| Rate for Payer: Healthscope Whirlpool |
$283.42
|
| Rate for Payer: Mclaren Commercial |
$262.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$248.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$204.53
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$257.13
|
|
|
HC NUSHIELD 4X4 PER SQ CM
|
Facility
|
OP
|
$227.11
|
|
|
Service Code
|
CPT Q4160
|
| Hospital Charge Code |
63600177
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$90.84 |
| Max. Negotiated Rate |
$227.11 |
| Rate for Payer: Aetna Commercial |
$204.40
|
| Rate for Payer: ASR ASR |
$220.30
|
| Rate for Payer: BCBS Complete |
$90.84
|
| Rate for Payer: BCBS Trust/PPO |
$176.08
|
| Rate for Payer: BCN Commercial |
$176.08
|
| Rate for Payer: Cash Price |
$181.69
|
| Rate for Payer: Cofinity Commercial |
$213.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$181.69
|
| Rate for Payer: Healthscope Commercial |
$227.11
|
| Rate for Payer: Healthscope Whirlpool |
$220.30
|
| Rate for Payer: Mclaren Commercial |
$204.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$193.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$158.98
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$206.67
|
| Rate for Payer: Priority Health Narrow Network |
$161.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$199.86
|
|
|
HC NUSHIELD 4X4 PER SQ CM
|
Facility
|
IP
|
$227.11
|
|
|
Service Code
|
CPT Q4160
|
| Hospital Charge Code |
63600177
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$158.98 |
| Max. Negotiated Rate |
$227.11 |
| Rate for Payer: Aetna Commercial |
$204.40
|
| Rate for Payer: ASR ASR |
$220.30
|
| Rate for Payer: BCBS Trust/PPO |
$176.08
|
| Rate for Payer: BCN Commercial |
$176.08
|
| Rate for Payer: Cash Price |
$181.69
|
| Rate for Payer: Cofinity Commercial |
$213.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$181.69
|
| Rate for Payer: Healthscope Commercial |
$227.11
|
| Rate for Payer: Healthscope Whirlpool |
$220.30
|
| Rate for Payer: Mclaren Commercial |
$204.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$193.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$158.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$199.86
|
|
|
HC NUSHIELD 4X6 PER SQ CM
|
Facility
|
IP
|
$159.38
|
|
|
Service Code
|
HCPCS Q4160
|
| Hospital Charge Code |
63600178
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$111.57 |
| Max. Negotiated Rate |
$159.38 |
| Rate for Payer: Aetna Commercial |
$143.44
|
| Rate for Payer: ASR ASR |
$154.60
|
| Rate for Payer: BCBS Trust/PPO |
$123.57
|
| Rate for Payer: BCN Commercial |
$123.57
|
| Rate for Payer: Cash Price |
$127.50
|
| Rate for Payer: Cofinity Commercial |
$149.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$127.50
|
| Rate for Payer: Healthscope Commercial |
$159.38
|
| Rate for Payer: Healthscope Whirlpool |
$154.60
|
| Rate for Payer: Mclaren Commercial |
$143.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$135.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$111.57
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$140.25
|
|
|
HC NUSHIELD 4X6 PER SQ CM
|
Facility
|
OP
|
$159.38
|
|
|
Service Code
|
HCPCS Q4160
|
| Hospital Charge Code |
63600178
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$63.75 |
| Max. Negotiated Rate |
$159.38 |
| Rate for Payer: Aetna Commercial |
$143.44
|
| Rate for Payer: ASR ASR |
$154.60
|
| Rate for Payer: BCBS Complete |
$63.75
|
| Rate for Payer: BCBS Trust/PPO |
$123.57
|
| Rate for Payer: BCN Commercial |
$123.57
|
| Rate for Payer: Cash Price |
$127.50
|
| Rate for Payer: Cofinity Commercial |
$149.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$127.50
|
| Rate for Payer: Healthscope Commercial |
$159.38
|
| Rate for Payer: Healthscope Whirlpool |
$154.60
|
| Rate for Payer: Mclaren Commercial |
$143.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$135.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$111.57
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$145.04
|
| Rate for Payer: Priority Health Narrow Network |
$113.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$140.25
|
|
|
HC NUSHIELD 6X6 PER SQ CM
|
Facility
|
IP
|
$141.11
|
|
|
Service Code
|
HCPCS Q4160
|
| Hospital Charge Code |
63600166
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$98.78 |
| Max. Negotiated Rate |
$141.11 |
| Rate for Payer: Aetna Commercial |
$127.00
|
| Rate for Payer: ASR ASR |
$136.88
|
| Rate for Payer: BCBS Trust/PPO |
$109.40
|
| Rate for Payer: BCN Commercial |
$109.40
|
| Rate for Payer: Cash Price |
$112.89
|
| Rate for Payer: Cofinity Commercial |
$132.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$112.89
|
| Rate for Payer: Healthscope Commercial |
$141.11
|
| Rate for Payer: Healthscope Whirlpool |
$136.88
|
| Rate for Payer: Mclaren Commercial |
$127.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$119.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$98.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$124.18
|
|
|
HC NUSHIELD 6X6 PER SQ CM
|
Facility
|
OP
|
$141.11
|
|
|
Service Code
|
HCPCS Q4160
|
| Hospital Charge Code |
63600166
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$56.44 |
| Max. Negotiated Rate |
$141.11 |
| Rate for Payer: Aetna Commercial |
$127.00
|
| Rate for Payer: ASR ASR |
$136.88
|
| Rate for Payer: BCBS Complete |
$56.44
|
| Rate for Payer: BCBS Trust/PPO |
$109.40
|
| Rate for Payer: BCN Commercial |
$109.40
|
| Rate for Payer: Cash Price |
$112.89
|
| Rate for Payer: Cofinity Commercial |
$132.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$112.89
|
| Rate for Payer: Healthscope Commercial |
$141.11
|
| Rate for Payer: Healthscope Whirlpool |
$136.88
|
| Rate for Payer: Mclaren Commercial |
$127.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$119.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$98.78
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$128.41
|
| Rate for Payer: Priority Health Narrow Network |
$100.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$124.18
|
|
