|
HC OSU OBSERVATION PER HOUR
|
Facility
|
IP
|
$145.08
|
|
|
Service Code
|
HCPCS G0378
|
| Hospital Charge Code |
76200009
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$94.30 |
| Max. Negotiated Rate |
$145.08 |
| Rate for Payer: Aetna Commercial |
$130.57
|
| Rate for Payer: ASR ASR |
$140.73
|
| Rate for Payer: ASR Commercial |
$140.73
|
| Rate for Payer: BCBS Trust/PPO |
$118.23
|
| Rate for Payer: BCN Commercial |
$112.48
|
| Rate for Payer: Cash Price |
$116.06
|
| Rate for Payer: Cofinity Commercial |
$136.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$116.06
|
| Rate for Payer: Healthscope Commercial |
$145.08
|
| Rate for Payer: Healthscope Whirlpool |
$140.73
|
| Rate for Payer: Mclaren Commercial |
$130.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$123.32
|
| Rate for Payer: Nomi Health Commercial |
$118.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$94.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$127.67
|
|
|
HC OT EVAL HIGH COMPLEXITY
|
Facility
|
OP
|
$279.25
|
|
|
Service Code
|
CPT 97167
|
| Hospital Charge Code |
43400009
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$111.70 |
| Max. Negotiated Rate |
$279.25 |
| Rate for Payer: Aetna Commercial |
$251.32
|
| Rate for Payer: Aetna Medicare |
$139.62
|
| Rate for Payer: ASR ASR |
$270.87
|
| Rate for Payer: ASR Commercial |
$270.87
|
| Rate for Payer: BCBS Complete |
$111.70
|
| Rate for Payer: BCBS Trust/PPO |
$228.68
|
| Rate for Payer: BCN Commercial |
$216.50
|
| Rate for Payer: Cash Price |
$223.40
|
| Rate for Payer: Cofinity Commercial |
$262.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$223.40
|
| Rate for Payer: Healthscope Commercial |
$279.25
|
| Rate for Payer: Healthscope Whirlpool |
$270.87
|
| Rate for Payer: Mclaren Commercial |
$251.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$237.36
|
| Rate for Payer: Nomi Health Commercial |
$228.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$181.51
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$244.68
|
| Rate for Payer: Priority Health Narrow Network |
$195.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$245.74
|
|
|
HC OT EVAL HIGH COMPLEXITY
|
Facility
|
IP
|
$279.25
|
|
|
Service Code
|
CPT 97167
|
| Hospital Charge Code |
43400009
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$181.51 |
| Max. Negotiated Rate |
$279.25 |
| Rate for Payer: Aetna Commercial |
$251.32
|
| Rate for Payer: ASR ASR |
$270.87
|
| Rate for Payer: ASR Commercial |
$270.87
|
| Rate for Payer: BCBS Trust/PPO |
$227.56
|
| Rate for Payer: BCN Commercial |
$216.50
|
| Rate for Payer: Cash Price |
$223.40
|
| Rate for Payer: Cofinity Commercial |
$262.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$223.40
|
| Rate for Payer: Healthscope Commercial |
$279.25
|
| Rate for Payer: Healthscope Whirlpool |
$270.87
|
| Rate for Payer: Mclaren Commercial |
$251.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$237.36
|
| Rate for Payer: Nomi Health Commercial |
$228.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$181.51
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$245.74
|
|
|
HC OT EVAL LOW COMPLEXITY
|
Facility
|
IP
|
$228.47
|
|
|
Service Code
|
CPT 97165
|
| Hospital Charge Code |
43400007
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$148.51 |
| Max. Negotiated Rate |
$228.47 |
| Rate for Payer: Aetna Commercial |
$205.62
|
| Rate for Payer: ASR ASR |
$221.62
|
| Rate for Payer: ASR Commercial |
$221.62
|
| Rate for Payer: BCBS Trust/PPO |
$186.18
|
| Rate for Payer: BCN Commercial |
$177.13
|
| Rate for Payer: Cash Price |
$182.78
|
| Rate for Payer: Cofinity Commercial |
$214.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$182.78
|
| Rate for Payer: Healthscope Commercial |
$228.47
|
| Rate for Payer: Healthscope Whirlpool |
$221.62
|
| Rate for Payer: Mclaren Commercial |
$205.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$194.20
|
| Rate for Payer: Nomi Health Commercial |
$187.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$148.51
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$201.05
|
|
|
HC OT EVAL LOW COMPLEXITY
|
Facility
|
OP
|
$228.47
|
|
|
Service Code
|
CPT 97165
|
| Hospital Charge Code |
43400007
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$91.39 |
| Max. Negotiated Rate |
$228.47 |
| Rate for Payer: Aetna Commercial |
$205.62
|
| Rate for Payer: Aetna Medicare |
$114.24
|
| Rate for Payer: ASR ASR |
$221.62
|
| Rate for Payer: ASR Commercial |
$221.62
|
| Rate for Payer: BCBS Complete |
$91.39
|
| Rate for Payer: BCBS Trust/PPO |
$187.09
|
| Rate for Payer: BCN Commercial |
$177.13
|
| Rate for Payer: Cash Price |
$182.78
|
| Rate for Payer: Cofinity Commercial |
$214.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$182.78
|
| Rate for Payer: Healthscope Commercial |
$228.47
|
| Rate for Payer: Healthscope Whirlpool |
$221.62
|
| Rate for Payer: Mclaren Commercial |
$205.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$194.20
|
| Rate for Payer: Nomi Health Commercial |
$187.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$148.51
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$200.19
|
| Rate for Payer: Priority Health Narrow Network |
$160.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$201.05
|
|
|
HC OT EVAL MODERATE COMPLEXITY
|
Facility
|
OP
|
$253.86
|
|
|
Service Code
|
CPT 97166
|
| Hospital Charge Code |
43400008
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$101.54 |
| Max. Negotiated Rate |
$253.86 |
| Rate for Payer: Aetna Commercial |
$228.47
|
| Rate for Payer: Aetna Medicare |
$126.93
|
| Rate for Payer: ASR ASR |
$246.24
|
| Rate for Payer: ASR Commercial |
$246.24
|
| Rate for Payer: BCBS Complete |
$101.54
|
| Rate for Payer: BCBS Trust/PPO |
$207.89
|
| Rate for Payer: BCN Commercial |
$196.82
|
| Rate for Payer: Cash Price |
$203.09
|
| Rate for Payer: Cofinity Commercial |
$238.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$203.09
|
| Rate for Payer: Healthscope Commercial |
$253.86
|
| Rate for Payer: Healthscope Whirlpool |
$246.24
|
| Rate for Payer: Mclaren Commercial |
$228.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$215.78
|
| Rate for Payer: Nomi Health Commercial |
$208.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$165.01
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$222.43
|
| Rate for Payer: Priority Health Narrow Network |
$177.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$223.40
|
|
|
HC OT EVAL MODERATE COMPLEXITY
|
Facility
|
IP
|
$253.86
|
|
|
Service Code
|
CPT 97166
|
| Hospital Charge Code |
43400008
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$165.01 |
| Max. Negotiated Rate |
$253.86 |
| Rate for Payer: Aetna Commercial |
$228.47
|
| Rate for Payer: ASR ASR |
$246.24
|
| Rate for Payer: ASR Commercial |
$246.24
|
| Rate for Payer: BCBS Trust/PPO |
$206.87
|
| Rate for Payer: BCN Commercial |
$196.82
|
| Rate for Payer: Cash Price |
$203.09
|
| Rate for Payer: Cofinity Commercial |
$238.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$203.09
|
| Rate for Payer: Healthscope Commercial |
$253.86
|
| Rate for Payer: Healthscope Whirlpool |
$246.24
|
| Rate for Payer: Mclaren Commercial |
$228.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$215.78
|
| Rate for Payer: Nomi Health Commercial |
$208.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$165.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$223.40
|
|
|
HC OT RE-EVALUATION
|
Facility
|
OP
|
$120.36
|
|
|
Service Code
|
CPT 97168
|
| Hospital Charge Code |
43400010
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$48.14 |
| Max. Negotiated Rate |
$120.36 |
| Rate for Payer: Aetna Commercial |
$108.32
|
| Rate for Payer: Aetna Medicare |
$60.18
|
| Rate for Payer: ASR ASR |
$116.75
|
| Rate for Payer: ASR Commercial |
$116.75
|
| Rate for Payer: BCBS Complete |
$48.14
|
| Rate for Payer: BCBS Trust/PPO |
$98.56
|
| Rate for Payer: BCN Commercial |
$93.32
|
| Rate for Payer: Cash Price |
$96.29
|
| Rate for Payer: Cofinity Commercial |
$113.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$96.29
|
| Rate for Payer: Healthscope Commercial |
$120.36
|
| Rate for Payer: Healthscope Whirlpool |
$116.75
|
| Rate for Payer: Mclaren Commercial |
$108.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$102.31
|
| Rate for Payer: Nomi Health Commercial |
$98.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$78.23
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$105.46
|
| Rate for Payer: Priority Health Narrow Network |
$84.37
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$105.92
|
|
|
HC OT RE-EVALUATION
|
Facility
|
IP
|
$120.36
|
|
|
Service Code
|
CPT 97168
|
| Hospital Charge Code |
43400010
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$78.23 |
| Max. Negotiated Rate |
$120.36 |
| Rate for Payer: Aetna Commercial |
$108.32
|
| Rate for Payer: ASR ASR |
$116.75
|
| Rate for Payer: ASR Commercial |
$116.75
|
| Rate for Payer: BCBS Trust/PPO |
$98.08
|
| Rate for Payer: BCN Commercial |
$93.32
|
| Rate for Payer: Cash Price |
$96.29
|
| Rate for Payer: Cofinity Commercial |
$113.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$96.29
|
| Rate for Payer: Healthscope Commercial |
$120.36
|
| Rate for Payer: Healthscope Whirlpool |
$116.75
|
| Rate for Payer: Mclaren Commercial |
$108.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$102.31
|
| Rate for Payer: Nomi Health Commercial |
$98.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$78.23
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$105.92
|
|
|
HC OT Z GAUNTLET EA $100
|
Facility
|
OP
|
$102.00
|
|
|
Service Code
|
HCPCS A6549
|
| Hospital Charge Code |
98300074
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$40.80 |
| Max. Negotiated Rate |
$102.00 |
| Rate for Payer: Aetna Commercial |
$91.80
|
| Rate for Payer: Aetna Medicare |
$51.00
|
| Rate for Payer: ASR ASR |
$98.94
|
| Rate for Payer: ASR Commercial |
$98.94
|
| Rate for Payer: BCBS Complete |
$40.80
|
| Rate for Payer: BCBS Trust/PPO |
$83.53
|
| Rate for Payer: BCN Commercial |
$79.08
|
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Cofinity Commercial |
$95.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$81.60
|
| Rate for Payer: Healthscope Commercial |
$102.00
|
| Rate for Payer: Healthscope Whirlpool |
$98.94
|
| Rate for Payer: Mclaren Commercial |
$91.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$86.70
|
| Rate for Payer: Nomi Health Commercial |
$83.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$66.30
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$89.37
|
| Rate for Payer: Priority Health Narrow Network |
$71.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$89.76
|
|
|
HC OT Z GAUNTLET EA $100
|
Facility
|
IP
|
$102.00
|
|
|
Service Code
|
HCPCS A6549
|
| Hospital Charge Code |
98300074
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$66.30 |
| Max. Negotiated Rate |
$102.00 |
| Rate for Payer: Aetna Commercial |
$91.80
|
| Rate for Payer: ASR ASR |
$98.94
|
| Rate for Payer: ASR Commercial |
$98.94
|
| Rate for Payer: BCBS Trust/PPO |
$83.12
|
| Rate for Payer: BCN Commercial |
$79.08
|
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Cofinity Commercial |
$95.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$81.60
|
| Rate for Payer: Healthscope Commercial |
$102.00
|
| Rate for Payer: Healthscope Whirlpool |
$98.94
|
| Rate for Payer: Mclaren Commercial |
$91.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$86.70
|
| Rate for Payer: Nomi Health Commercial |
$83.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$66.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$89.76
|
|
|
HC OT Z GAUNTLET EA $125
|
Facility
|
IP
|
$127.50
|
|
|
Service Code
|
HCPCS A6549
|
| Hospital Charge Code |
98300075
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$82.88 |
| Max. Negotiated Rate |
$127.50 |
| Rate for Payer: Aetna Commercial |
$114.75
|
| Rate for Payer: ASR ASR |
$123.68
|
| Rate for Payer: ASR Commercial |
$123.68
|
| Rate for Payer: BCBS Trust/PPO |
$103.90
|
| Rate for Payer: BCN Commercial |
$98.85
|
| Rate for Payer: Cash Price |
$102.00
|
| Rate for Payer: Cofinity Commercial |
$119.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$102.00
|
| Rate for Payer: Healthscope Commercial |
$127.50
|
| Rate for Payer: Healthscope Whirlpool |
$123.68
|
| Rate for Payer: Mclaren Commercial |
$114.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$108.38
|
| Rate for Payer: Nomi Health Commercial |
$104.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$82.88
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$112.20
|
|
|
HC OT Z GAUNTLET EA $125
|
Facility
|
OP
|
$127.50
|
|
|
Service Code
|
HCPCS A6549
|
| Hospital Charge Code |
98300075
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$51.00 |
| Max. Negotiated Rate |
$127.50 |
| Rate for Payer: Aetna Commercial |
$114.75
|
| Rate for Payer: Aetna Medicare |
$63.75
|
| Rate for Payer: ASR ASR |
$123.68
|
| Rate for Payer: ASR Commercial |
$123.68
|
| Rate for Payer: BCBS Complete |
$51.00
|
| Rate for Payer: BCBS Trust/PPO |
$104.41
|
| Rate for Payer: BCN Commercial |
$98.85
|
| Rate for Payer: Cash Price |
$102.00
|
| Rate for Payer: Cofinity Commercial |
$119.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$102.00
|
| Rate for Payer: Healthscope Commercial |
$127.50
|
| Rate for Payer: Healthscope Whirlpool |
$123.68
|
| Rate for Payer: Mclaren Commercial |
$114.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$108.38
|
| Rate for Payer: Nomi Health Commercial |
$104.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$82.88
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$111.72
|
| Rate for Payer: Priority Health Narrow Network |
$89.38
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$112.20
|
|
|
HC OT Z GAUNTLET EA $150
|
Facility
|
IP
|
$153.00
|
|
|
Service Code
|
HCPCS A6549
|
| Hospital Charge Code |
98300076
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$99.45 |
| Max. Negotiated Rate |
$153.00 |
| Rate for Payer: Aetna Commercial |
$137.70
|
| Rate for Payer: ASR ASR |
$148.41
|
| Rate for Payer: ASR Commercial |
$148.41
|
| Rate for Payer: BCBS Trust/PPO |
$124.68
|
| Rate for Payer: BCN Commercial |
$118.62
|
| Rate for Payer: Cash Price |
$122.40
|
| Rate for Payer: Cofinity Commercial |
$143.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$122.40
|
| Rate for Payer: Healthscope Commercial |
$153.00
|
| Rate for Payer: Healthscope Whirlpool |
$148.41
|
| Rate for Payer: Mclaren Commercial |
$137.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$130.05
|
| Rate for Payer: Nomi Health Commercial |
$125.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$99.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$134.64
|
|
|
HC OT Z GAUNTLET EA $150
|
Facility
|
OP
|
$153.00
|
|
|
Service Code
|
HCPCS A6549
|
| Hospital Charge Code |
98300076
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$61.20 |
| Max. Negotiated Rate |
$153.00 |
| Rate for Payer: Aetna Commercial |
$137.70
|
| Rate for Payer: Aetna Medicare |
$76.50
|
| Rate for Payer: ASR ASR |
$148.41
|
| Rate for Payer: ASR Commercial |
$148.41
|
| Rate for Payer: BCBS Complete |
$61.20
|
| Rate for Payer: BCBS Trust/PPO |
$125.29
|
| Rate for Payer: BCN Commercial |
$118.62
|
| Rate for Payer: Cash Price |
$122.40
|
| Rate for Payer: Cofinity Commercial |
$143.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$122.40
|
| Rate for Payer: Healthscope Commercial |
$153.00
|
| Rate for Payer: Healthscope Whirlpool |
$148.41
|
| Rate for Payer: Mclaren Commercial |
$137.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$130.05
|
| Rate for Payer: Nomi Health Commercial |
$125.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$99.45
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$134.06
|
| Rate for Payer: Priority Health Narrow Network |
$107.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$134.64
|
|
|
HC OT Z GAUNTLET EA $175
|
Facility
|
IP
|
$178.50
|
|
|
Service Code
|
HCPCS A6549
|
| Hospital Charge Code |
98300077
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$116.02 |
| Max. Negotiated Rate |
$178.50 |
| Rate for Payer: Aetna Commercial |
$160.65
|
| Rate for Payer: ASR ASR |
$173.14
|
| Rate for Payer: ASR Commercial |
$173.14
|
| Rate for Payer: BCBS Trust/PPO |
$145.46
|
| Rate for Payer: BCN Commercial |
$138.39
|
| Rate for Payer: Cash Price |
$142.80
|
| Rate for Payer: Cofinity Commercial |
$167.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$142.80
|
| Rate for Payer: Healthscope Commercial |
$178.50
|
| Rate for Payer: Healthscope Whirlpool |
$173.14
|
| Rate for Payer: Mclaren Commercial |
$160.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$151.72
|
| Rate for Payer: Nomi Health Commercial |
$146.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$116.02
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$157.08
|
|
|
HC OT Z GAUNTLET EA $175
|
Facility
|
OP
|
$178.50
|
|
|
Service Code
|
HCPCS A6549
|
| Hospital Charge Code |
98300077
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$71.40 |
| Max. Negotiated Rate |
$178.50 |
| Rate for Payer: Aetna Commercial |
$160.65
|
| Rate for Payer: Aetna Medicare |
$89.25
|
| Rate for Payer: ASR ASR |
$173.14
|
| Rate for Payer: ASR Commercial |
$173.14
|
| Rate for Payer: BCBS Complete |
$71.40
|
| Rate for Payer: BCBS Trust/PPO |
$146.17
|
| Rate for Payer: BCN Commercial |
$138.39
|
| Rate for Payer: Cash Price |
$142.80
|
| Rate for Payer: Cofinity Commercial |
$167.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$142.80
|
| Rate for Payer: Healthscope Commercial |
$178.50
|
| Rate for Payer: Healthscope Whirlpool |
$173.14
|
| Rate for Payer: Mclaren Commercial |
$160.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$151.72
|
| Rate for Payer: Nomi Health Commercial |
$146.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$116.02
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$156.40
|
| Rate for Payer: Priority Health Narrow Network |
$125.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$157.08
|
|
|
HC OT Z GAUNTLET EA $20
|
Facility
|
OP
|
$20.40
|
|
|
Service Code
|
HCPCS A6549
|
| Hospital Charge Code |
98300078
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$8.16 |
| Max. Negotiated Rate |
$20.40 |
| Rate for Payer: Aetna Commercial |
$18.36
|
| Rate for Payer: Aetna Medicare |
$10.20
|
| Rate for Payer: ASR ASR |
$19.79
|
| Rate for Payer: ASR Commercial |
$19.79
|
| Rate for Payer: BCBS Complete |
$8.16
|
| Rate for Payer: BCBS Trust/PPO |
$16.71
|
| Rate for Payer: BCN Commercial |
$15.82
|
| Rate for Payer: Cash Price |
$16.32
|
| Rate for Payer: Cofinity Commercial |
$19.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.32
|
| Rate for Payer: Healthscope Commercial |
$20.40
|
| Rate for Payer: Healthscope Whirlpool |
$19.79
|
| Rate for Payer: Mclaren Commercial |
$18.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.34
|
| Rate for Payer: Nomi Health Commercial |
$16.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.26
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$17.87
|
| Rate for Payer: Priority Health Narrow Network |
$14.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$17.95
|
|
|
HC OT Z GAUNTLET EA $20
|
Facility
|
IP
|
$20.40
|
|
|
Service Code
|
HCPCS A6549
|
| Hospital Charge Code |
98300078
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$13.26 |
| Max. Negotiated Rate |
$20.40 |
| Rate for Payer: Aetna Commercial |
$18.36
|
| Rate for Payer: ASR ASR |
$19.79
|
| Rate for Payer: ASR Commercial |
$19.79
|
| Rate for Payer: BCBS Trust/PPO |
$16.62
|
| Rate for Payer: BCN Commercial |
$15.82
|
| Rate for Payer: Cash Price |
$16.32
|
| Rate for Payer: Cofinity Commercial |
$19.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.32
|
| Rate for Payer: Healthscope Commercial |
$20.40
|
| Rate for Payer: Healthscope Whirlpool |
$19.79
|
| Rate for Payer: Mclaren Commercial |
$18.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.34
|
| Rate for Payer: Nomi Health Commercial |
$16.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.26
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$17.95
|
|
|
HC OT Z GAUNTLET EA $200
|
Facility
|
OP
|
$204.00
|
|
|
Service Code
|
HCPCS A6549
|
| Hospital Charge Code |
98300079
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$81.60 |
| Max. Negotiated Rate |
$204.00 |
| Rate for Payer: Aetna Commercial |
$183.60
|
| Rate for Payer: Aetna Medicare |
$102.00
|
| Rate for Payer: ASR ASR |
$197.88
|
| Rate for Payer: ASR Commercial |
$197.88
|
| Rate for Payer: BCBS Complete |
$81.60
|
| Rate for Payer: BCBS Trust/PPO |
$167.06
|
| Rate for Payer: BCN Commercial |
$158.16
|
| Rate for Payer: Cash Price |
$163.20
|
| Rate for Payer: Cofinity Commercial |
$191.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$163.20
|
| Rate for Payer: Healthscope Commercial |
$204.00
|
| Rate for Payer: Healthscope Whirlpool |
$197.88
|
| Rate for Payer: Mclaren Commercial |
$183.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$173.40
|
| Rate for Payer: Nomi Health Commercial |
$167.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$132.60
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$178.74
|
| Rate for Payer: Priority Health Narrow Network |
$143.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$179.52
|
|
|
HC OT Z GAUNTLET EA $200
|
Facility
|
IP
|
$204.00
|
|
|
Service Code
|
HCPCS A6549
|
| Hospital Charge Code |
98300079
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$132.60 |
| Max. Negotiated Rate |
$204.00 |
| Rate for Payer: Aetna Commercial |
$183.60
|
| Rate for Payer: ASR ASR |
$197.88
|
| Rate for Payer: ASR Commercial |
$197.88
|
| Rate for Payer: BCBS Trust/PPO |
$166.24
|
| Rate for Payer: BCN Commercial |
$158.16
|
| Rate for Payer: Cash Price |
$163.20
|
| Rate for Payer: Cofinity Commercial |
$191.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$163.20
|
| Rate for Payer: Healthscope Commercial |
$204.00
|
| Rate for Payer: Healthscope Whirlpool |
$197.88
|
| Rate for Payer: Mclaren Commercial |
$183.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$173.40
|
| Rate for Payer: Nomi Health Commercial |
$167.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$132.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$179.52
|
|
|
HC OT Z GAUNTLET EA $225
|
Facility
|
IP
|
$229.50
|
|
|
Service Code
|
HCPCS A6549
|
| Hospital Charge Code |
98300080
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$149.18 |
| Max. Negotiated Rate |
$229.50 |
| Rate for Payer: Aetna Commercial |
$206.55
|
| Rate for Payer: ASR ASR |
$222.62
|
| Rate for Payer: ASR Commercial |
$222.62
|
| Rate for Payer: BCBS Trust/PPO |
$187.02
|
| Rate for Payer: BCN Commercial |
$177.93
|
| Rate for Payer: Cash Price |
$183.60
|
| Rate for Payer: Cofinity Commercial |
$215.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$183.60
|
| Rate for Payer: Healthscope Commercial |
$229.50
|
| Rate for Payer: Healthscope Whirlpool |
$222.62
|
| Rate for Payer: Mclaren Commercial |
$206.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$195.08
|
| Rate for Payer: Nomi Health Commercial |
$188.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$149.18
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$201.96
|
|
|
HC OT Z GAUNTLET EA $225
|
Facility
|
OP
|
$229.50
|
|
|
Service Code
|
HCPCS A6549
|
| Hospital Charge Code |
98300080
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$91.80 |
| Max. Negotiated Rate |
$229.50 |
| Rate for Payer: Aetna Commercial |
$206.55
|
| Rate for Payer: Aetna Medicare |
$114.75
|
| Rate for Payer: ASR ASR |
$222.62
|
| Rate for Payer: ASR Commercial |
$222.62
|
| Rate for Payer: BCBS Complete |
$91.80
|
| Rate for Payer: BCBS Trust/PPO |
$187.94
|
| Rate for Payer: BCN Commercial |
$177.93
|
| Rate for Payer: Cash Price |
$183.60
|
| Rate for Payer: Cofinity Commercial |
$215.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$183.60
|
| Rate for Payer: Healthscope Commercial |
$229.50
|
| Rate for Payer: Healthscope Whirlpool |
$222.62
|
| Rate for Payer: Mclaren Commercial |
$206.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$195.08
|
| Rate for Payer: Nomi Health Commercial |
$188.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$149.18
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$201.09
|
| Rate for Payer: Priority Health Narrow Network |
$160.88
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$201.96
|
|
|
HC OT Z GAUNTLET EA $250
|
Facility
|
IP
|
$255.00
|
|
|
Service Code
|
HCPCS A6549
|
| Hospital Charge Code |
98300081
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$165.75 |
| Max. Negotiated Rate |
$255.00 |
| Rate for Payer: Aetna Commercial |
$229.50
|
| Rate for Payer: ASR ASR |
$247.35
|
| Rate for Payer: ASR Commercial |
$247.35
|
| Rate for Payer: BCBS Trust/PPO |
$207.80
|
| Rate for Payer: BCN Commercial |
$197.70
|
| Rate for Payer: Cash Price |
$204.00
|
| Rate for Payer: Cofinity Commercial |
$239.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$204.00
|
| Rate for Payer: Healthscope Commercial |
$255.00
|
| Rate for Payer: Healthscope Whirlpool |
$247.35
|
| Rate for Payer: Mclaren Commercial |
$229.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$216.75
|
| Rate for Payer: Nomi Health Commercial |
$209.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$165.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$224.40
|
|
|
HC OT Z GAUNTLET EA $250
|
Facility
|
OP
|
$255.00
|
|
|
Service Code
|
HCPCS A6549
|
| Hospital Charge Code |
98300081
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$102.00 |
| Max. Negotiated Rate |
$255.00 |
| Rate for Payer: Aetna Commercial |
$229.50
|
| Rate for Payer: Aetna Medicare |
$127.50
|
| Rate for Payer: ASR ASR |
$247.35
|
| Rate for Payer: ASR Commercial |
$247.35
|
| Rate for Payer: BCBS Complete |
$102.00
|
| Rate for Payer: BCBS Trust/PPO |
$208.82
|
| Rate for Payer: BCN Commercial |
$197.70
|
| Rate for Payer: Cash Price |
$204.00
|
| Rate for Payer: Cofinity Commercial |
$239.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$204.00
|
| Rate for Payer: Healthscope Commercial |
$255.00
|
| Rate for Payer: Healthscope Whirlpool |
$247.35
|
| Rate for Payer: Mclaren Commercial |
$229.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$216.75
|
| Rate for Payer: Nomi Health Commercial |
$209.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$165.75
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$223.43
|
| Rate for Payer: Priority Health Narrow Network |
$178.76
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$224.40
|
|
