|
HC PUNCTURE WITH INJECTION CERVICAL
|
Facility
|
IP
|
$793.26
|
|
|
Service Code
|
CPT 61055
|
| Hospital Charge Code |
36100269
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$594.95 |
| Max. Negotiated Rate |
$793.26 |
| Rate for Payer: Aetna Commercial |
$713.93
|
| Rate for Payer: ASR ASR |
$769.46
|
| Rate for Payer: BCBS Trust/PPO |
$651.43
|
| Rate for Payer: BCN Commercial |
$651.43
|
| Rate for Payer: Cash Price |
$634.61
|
| Rate for Payer: Cofinity Commercial |
$745.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$634.61
|
| Rate for Payer: Healthscope Commercial |
$769.46
|
| Rate for Payer: Healthscope Whirlpool |
$793.26
|
| Rate for Payer: Mclaren Commercial |
$713.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$674.27
|
| Rate for Payer: Nomi Health Commercial |
$650.47
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$594.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$698.07
|
|
|
HC PUNCTURE WITH INJECTION CERVICAL
|
Facility
|
OP
|
$793.26
|
|
|
Service Code
|
CPT 61055
|
| Hospital Charge Code |
36100269
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$159.96 |
| Max. Negotiated Rate |
$793.26 |
| Rate for Payer: Aetna Commercial |
$713.93
|
| Rate for Payer: Aetna Medicare |
$305.85
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$382.31
|
| Rate for Payer: Amish Plain Church Group Commercial |
$382.31
|
| Rate for Payer: ASR ASR |
$769.46
|
| Rate for Payer: BCBS Complete |
$167.97
|
| Rate for Payer: BCBS MAPPO |
$305.85
|
| Rate for Payer: BCBS Trust/PPO |
$654.04
|
| Rate for Payer: BCN Commercial |
$654.04
|
| Rate for Payer: BCN Medicare Advantage |
$305.85
|
| Rate for Payer: Cash Price |
$634.61
|
| Rate for Payer: Cash Price |
$634.61
|
| Rate for Payer: Cofinity Commercial |
$745.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$634.61
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$305.85
|
| Rate for Payer: Healthscope Commercial |
$769.46
|
| Rate for Payer: Healthscope Whirlpool |
$793.26
|
| Rate for Payer: Humana Choice PPO Medicare |
$305.85
|
| Rate for Payer: Mclaren Commercial |
$713.93
|
| Rate for Payer: Mclaren Medicaid |
$305.85
|
| Rate for Payer: Mclaren Medicare |
$305.85
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$321.14
|
| Rate for Payer: Meridian Medicaid |
$167.97
|
| Rate for Payer: MI Amish Medical Board Commercial |
$351.73
|
| Rate for Payer: Molina Medicare/Medicaid |
$336.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$674.27
|
| Rate for Payer: Nomi Health Commercial |
$650.47
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$594.95
|
| Rate for Payer: PACE Medicare |
$290.56
|
| Rate for Payer: PACE SWMI |
$305.85
|
| Rate for Payer: PHP Commercial |
$336.44
|
| Rate for Payer: PHP Medicaid |
$163.94
|
| Rate for Payer: PHP Medicare Advantage |
$305.85
|
| Rate for Payer: Priority Health Choice Medicaid |
$159.96
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$695.05
|
| Rate for Payer: Priority Health Medicare |
$305.85
|
| Rate for Payer: Priority Health Narrow Network |
$556.08
|
| Rate for Payer: Railroad Medicare Medicare |
$305.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$698.07
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$305.85
|
| Rate for Payer: UHC Exchange |
$474.07
|
| Rate for Payer: UHC Medicaid |
$159.96
|
| Rate for Payer: UHCCP DNSP |
$305.85
|
| Rate for Payer: UHCCP Medicaid |
$159.96
|
| Rate for Payer: VA VA |
$305.85
|
|
|
HC PURAPLY AM (1.6 SQ CM DISC) PER SQ CM
|
Facility
|
OP
|
$752.14
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
63600128
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$64.85 |
| Max. Negotiated Rate |
$752.14 |
| Rate for Payer: Aetna Commercial |
$676.93
|
| Rate for Payer: Aetna Medicare |
$124.00
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$155.00
|
| Rate for Payer: Amish Plain Church Group Commercial |
$155.00
|
| Rate for Payer: ASR ASR |
$729.58
|
| Rate for Payer: BCBS Complete |
$68.10
|
| Rate for Payer: BCBS MAPPO |
$124.00
|
| Rate for Payer: BCBS Trust/PPO |
$620.14
|
| Rate for Payer: BCN Commercial |
$620.14
|
| Rate for Payer: BCN Medicare Advantage |
$124.00
|
| Rate for Payer: Cash Price |
$601.71
|
| Rate for Payer: Cash Price |
$601.71
|
| Rate for Payer: Cofinity Commercial |
$707.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$601.71
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$124.00
|
| Rate for Payer: Healthscope Commercial |
$729.58
|
| Rate for Payer: Healthscope Whirlpool |
$752.14
|
| Rate for Payer: Humana Choice PPO Medicare |
$124.00
|
| Rate for Payer: Mclaren Commercial |
$676.93
|
| Rate for Payer: Mclaren Medicaid |
$124.00
|
| Rate for Payer: Mclaren Medicare |
$124.00
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$130.20
|
| Rate for Payer: Meridian Medicaid |
$68.10
|
| Rate for Payer: MI Amish Medical Board Commercial |
$142.60
|
| Rate for Payer: Molina Medicare/Medicaid |
$136.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$639.32
|
| Rate for Payer: Nomi Health Commercial |
$616.75
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$564.11
|
| Rate for Payer: PACE Medicare |
$117.80
|
| Rate for Payer: PACE SWMI |
$124.00
|
| Rate for Payer: PHP Commercial |
$136.40
|
| Rate for Payer: PHP Medicaid |
$66.46
|
| Rate for Payer: PHP Medicare Advantage |
$124.00
|
| Rate for Payer: Priority Health Choice Medicaid |
$64.85
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$174.32
|
| Rate for Payer: Priority Health Medicare |
$124.00
|
| Rate for Payer: Priority Health Narrow Network |
$139.46
|
| Rate for Payer: Railroad Medicare Medicare |
$124.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$661.88
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$124.00
|
| Rate for Payer: UHC Exchange |
$192.20
|
| Rate for Payer: UHC Medicaid |
$64.85
|
| Rate for Payer: UHCCP DNSP |
$124.00
|
| Rate for Payer: UHCCP Medicaid |
$64.85
|
| Rate for Payer: VA VA |
$124.00
|
|
|
HC PURAPLY AM (1.6 SQ CM DISC) PER SQ CM
|
Facility
|
IP
|
$752.14
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
63600128
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$564.11 |
| Max. Negotiated Rate |
$752.14 |
| Rate for Payer: Aetna Commercial |
$676.93
|
| Rate for Payer: ASR ASR |
$729.58
|
| Rate for Payer: BCBS Trust/PPO |
$617.66
|
| Rate for Payer: BCN Commercial |
$617.66
|
| Rate for Payer: Cash Price |
$601.71
|
| Rate for Payer: Cofinity Commercial |
$707.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$601.71
|
| Rate for Payer: Healthscope Commercial |
$729.58
|
| Rate for Payer: Healthscope Whirlpool |
$752.14
|
| Rate for Payer: Mclaren Commercial |
$676.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$639.32
|
| Rate for Payer: Nomi Health Commercial |
$616.75
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$564.11
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$661.88
|
|
|
HC PURAPLY AM 2X2 PER SQ CM
|
Facility
|
IP
|
$522.31
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
63600115
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$391.73 |
| Max. Negotiated Rate |
$522.31 |
| Rate for Payer: Aetna Commercial |
$470.08
|
| Rate for Payer: ASR ASR |
$506.64
|
| Rate for Payer: BCBS Trust/PPO |
$428.92
|
| Rate for Payer: BCN Commercial |
$428.92
|
| Rate for Payer: Cash Price |
$417.85
|
| Rate for Payer: Cofinity Commercial |
$490.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$417.85
|
| Rate for Payer: Healthscope Commercial |
$506.64
|
| Rate for Payer: Healthscope Whirlpool |
$522.31
|
| Rate for Payer: Mclaren Commercial |
$470.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$443.96
|
| Rate for Payer: Nomi Health Commercial |
$428.29
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$391.73
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$459.63
|
|
|
HC PURAPLY AM 2X2 PER SQ CM
|
Facility
|
OP
|
$522.31
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
63600115
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$64.85 |
| Max. Negotiated Rate |
$522.31 |
| Rate for Payer: Aetna Commercial |
$470.08
|
| Rate for Payer: Aetna Medicare |
$124.00
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$155.00
|
| Rate for Payer: Amish Plain Church Group Commercial |
$155.00
|
| Rate for Payer: ASR ASR |
$506.64
|
| Rate for Payer: BCBS Complete |
$68.10
|
| Rate for Payer: BCBS MAPPO |
$124.00
|
| Rate for Payer: BCBS Trust/PPO |
$430.64
|
| Rate for Payer: BCN Commercial |
$430.64
|
| Rate for Payer: BCN Medicare Advantage |
$124.00
|
| Rate for Payer: Cash Price |
$417.85
|
| Rate for Payer: Cash Price |
$417.85
|
| Rate for Payer: Cofinity Commercial |
$490.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$417.85
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$124.00
|
| Rate for Payer: Healthscope Commercial |
$506.64
|
| Rate for Payer: Healthscope Whirlpool |
$522.31
|
| Rate for Payer: Humana Choice PPO Medicare |
$124.00
|
| Rate for Payer: Mclaren Commercial |
$470.08
|
| Rate for Payer: Mclaren Medicaid |
$124.00
|
| Rate for Payer: Mclaren Medicare |
$124.00
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$130.20
|
| Rate for Payer: Meridian Medicaid |
$68.10
|
| Rate for Payer: MI Amish Medical Board Commercial |
$142.60
|
| Rate for Payer: Molina Medicare/Medicaid |
$136.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$443.96
|
| Rate for Payer: Nomi Health Commercial |
$428.29
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$391.73
|
| Rate for Payer: PACE Medicare |
$117.80
|
| Rate for Payer: PACE SWMI |
$124.00
|
| Rate for Payer: PHP Commercial |
$136.40
|
| Rate for Payer: PHP Medicaid |
$66.46
|
| Rate for Payer: PHP Medicare Advantage |
$124.00
|
| Rate for Payer: Priority Health Choice Medicaid |
$64.85
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$174.32
|
| Rate for Payer: Priority Health Medicare |
$124.00
|
| Rate for Payer: Priority Health Narrow Network |
$139.46
|
| Rate for Payer: Railroad Medicare Medicare |
$124.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$459.63
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$124.00
|
| Rate for Payer: UHC Exchange |
$192.20
|
| Rate for Payer: UHC Medicaid |
$64.85
|
| Rate for Payer: UHCCP DNSP |
$124.00
|
| Rate for Payer: UHCCP Medicaid |
$64.85
|
| Rate for Payer: VA VA |
$124.00
|
|
|
HC PURAPLY AM 2X4 PER SQ CM
|
Facility
|
OP
|
$330.80
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
63600116
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$64.85 |
| Max. Negotiated Rate |
$330.80 |
| Rate for Payer: Aetna Commercial |
$297.72
|
| Rate for Payer: Aetna Medicare |
$124.00
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$155.00
|
| Rate for Payer: Amish Plain Church Group Commercial |
$155.00
|
| Rate for Payer: ASR ASR |
$320.88
|
| Rate for Payer: BCBS Complete |
$68.10
|
| Rate for Payer: BCBS MAPPO |
$124.00
|
| Rate for Payer: BCBS Trust/PPO |
$272.74
|
| Rate for Payer: BCN Commercial |
$272.74
|
| Rate for Payer: BCN Medicare Advantage |
$124.00
|
| Rate for Payer: Cash Price |
$264.64
|
| Rate for Payer: Cash Price |
$264.64
|
| Rate for Payer: Cofinity Commercial |
$310.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$264.64
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$124.00
|
| Rate for Payer: Healthscope Commercial |
$320.88
|
| Rate for Payer: Healthscope Whirlpool |
$330.80
|
| Rate for Payer: Humana Choice PPO Medicare |
$124.00
|
| Rate for Payer: Mclaren Commercial |
$297.72
|
| Rate for Payer: Mclaren Medicaid |
$124.00
|
| Rate for Payer: Mclaren Medicare |
$124.00
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$130.20
|
| Rate for Payer: Meridian Medicaid |
$68.10
|
| Rate for Payer: MI Amish Medical Board Commercial |
$142.60
|
| Rate for Payer: Molina Medicare/Medicaid |
$136.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$281.18
|
| Rate for Payer: Nomi Health Commercial |
$271.26
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$248.10
|
| Rate for Payer: PACE Medicare |
$117.80
|
| Rate for Payer: PACE SWMI |
$124.00
|
| Rate for Payer: PHP Commercial |
$136.40
|
| Rate for Payer: PHP Medicaid |
$66.46
|
| Rate for Payer: PHP Medicare Advantage |
$124.00
|
| Rate for Payer: Priority Health Choice Medicaid |
$64.85
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$174.32
|
| Rate for Payer: Priority Health Medicare |
$124.00
|
| Rate for Payer: Priority Health Narrow Network |
$139.46
|
| Rate for Payer: Railroad Medicare Medicare |
$124.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$291.10
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$124.00
|
| Rate for Payer: UHC Exchange |
$192.20
|
| Rate for Payer: UHC Medicaid |
$64.85
|
| Rate for Payer: UHCCP DNSP |
$124.00
|
| Rate for Payer: UHCCP Medicaid |
$64.85
|
| Rate for Payer: VA VA |
$124.00
|
|
|
HC PURAPLY AM 2X4 PER SQ CM
|
Facility
|
IP
|
$330.80
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
63600116
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$248.10 |
| Max. Negotiated Rate |
$330.80 |
| Rate for Payer: Aetna Commercial |
$297.72
|
| Rate for Payer: ASR ASR |
$320.88
|
| Rate for Payer: BCBS Trust/PPO |
$271.65
|
| Rate for Payer: BCN Commercial |
$271.65
|
| Rate for Payer: Cash Price |
$264.64
|
| Rate for Payer: Cofinity Commercial |
$310.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$264.64
|
| Rate for Payer: Healthscope Commercial |
$320.88
|
| Rate for Payer: Healthscope Whirlpool |
$330.80
|
| Rate for Payer: Mclaren Commercial |
$297.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$281.18
|
| Rate for Payer: Nomi Health Commercial |
$271.26
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$248.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$291.10
|
|
|
HC PURAPLY AM 3X4 PER SQ CM
|
Facility
|
IP
|
$276.36
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
63600185
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$207.27 |
| Max. Negotiated Rate |
$276.36 |
| Rate for Payer: Aetna Commercial |
$248.72
|
| Rate for Payer: ASR ASR |
$268.07
|
| Rate for Payer: BCBS Trust/PPO |
$226.95
|
| Rate for Payer: BCN Commercial |
$226.95
|
| Rate for Payer: Cash Price |
$221.09
|
| Rate for Payer: Cofinity Commercial |
$259.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$221.09
|
| Rate for Payer: Healthscope Commercial |
$268.07
|
| Rate for Payer: Healthscope Whirlpool |
$276.36
|
| Rate for Payer: Mclaren Commercial |
$248.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$234.91
|
| Rate for Payer: Nomi Health Commercial |
$226.62
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$207.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$243.20
|
|
|
HC PURAPLY AM 3X4 PER SQ CM
|
Facility
|
OP
|
$276.36
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
63600185
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$64.85 |
| Max. Negotiated Rate |
$276.36 |
| Rate for Payer: Aetna Commercial |
$248.72
|
| Rate for Payer: Aetna Medicare |
$124.00
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$155.00
|
| Rate for Payer: Amish Plain Church Group Commercial |
$155.00
|
| Rate for Payer: ASR ASR |
$268.07
|
| Rate for Payer: BCBS Complete |
$68.10
|
| Rate for Payer: BCBS MAPPO |
$124.00
|
| Rate for Payer: BCBS Trust/PPO |
$227.86
|
| Rate for Payer: BCN Commercial |
$227.86
|
| Rate for Payer: BCN Medicare Advantage |
$124.00
|
| Rate for Payer: Cash Price |
$221.09
|
| Rate for Payer: Cash Price |
$221.09
|
| Rate for Payer: Cofinity Commercial |
$259.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$221.09
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$124.00
|
| Rate for Payer: Healthscope Commercial |
$268.07
|
| Rate for Payer: Healthscope Whirlpool |
$276.36
|
| Rate for Payer: Humana Choice PPO Medicare |
$124.00
|
| Rate for Payer: Mclaren Commercial |
$248.72
|
| Rate for Payer: Mclaren Medicaid |
$124.00
|
| Rate for Payer: Mclaren Medicare |
$124.00
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$130.20
|
| Rate for Payer: Meridian Medicaid |
$68.10
|
| Rate for Payer: MI Amish Medical Board Commercial |
$142.60
|
| Rate for Payer: Molina Medicare/Medicaid |
$136.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$234.91
|
| Rate for Payer: Nomi Health Commercial |
$226.62
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$207.27
|
| Rate for Payer: PACE Medicare |
$117.80
|
| Rate for Payer: PACE SWMI |
$124.00
|
| Rate for Payer: PHP Commercial |
$136.40
|
| Rate for Payer: PHP Medicaid |
$66.46
|
| Rate for Payer: PHP Medicare Advantage |
$124.00
|
| Rate for Payer: Priority Health Choice Medicaid |
$64.85
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$174.32
|
| Rate for Payer: Priority Health Medicare |
$124.00
|
| Rate for Payer: Priority Health Narrow Network |
$139.46
|
| Rate for Payer: Railroad Medicare Medicare |
$124.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$243.20
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$124.00
|
| Rate for Payer: UHC Exchange |
$192.20
|
| Rate for Payer: UHC Medicaid |
$64.85
|
| Rate for Payer: UHCCP DNSP |
$124.00
|
| Rate for Payer: UHCCP Medicaid |
$64.85
|
| Rate for Payer: VA VA |
$124.00
|
|
|
HC PURAPLY AM 4X3 PER SQ CM EXTRA FENESTRATED
|
Facility
|
IP
|
$291.83
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
63600183
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$218.87 |
| Max. Negotiated Rate |
$291.83 |
| Rate for Payer: Aetna Commercial |
$262.65
|
| Rate for Payer: ASR ASR |
$283.08
|
| Rate for Payer: BCBS Trust/PPO |
$239.65
|
| Rate for Payer: BCN Commercial |
$239.65
|
| Rate for Payer: Cash Price |
$233.46
|
| Rate for Payer: Cofinity Commercial |
$274.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$233.46
|
| Rate for Payer: Healthscope Commercial |
$283.08
|
| Rate for Payer: Healthscope Whirlpool |
$291.83
|
| Rate for Payer: Mclaren Commercial |
$262.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$248.06
|
| Rate for Payer: Nomi Health Commercial |
$239.30
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$218.87
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$256.81
|
|
|
HC PURAPLY AM 4X3 PER SQ CM EXTRA FENESTRATED
|
Facility
|
OP
|
$291.83
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
63600183
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$64.85 |
| Max. Negotiated Rate |
$291.83 |
| Rate for Payer: Aetna Commercial |
$262.65
|
| Rate for Payer: Aetna Medicare |
$124.00
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$155.00
|
| Rate for Payer: Amish Plain Church Group Commercial |
$155.00
|
| Rate for Payer: ASR ASR |
$283.08
|
| Rate for Payer: BCBS Complete |
$68.10
|
| Rate for Payer: BCBS MAPPO |
$124.00
|
| Rate for Payer: BCBS Trust/PPO |
$240.61
|
| Rate for Payer: BCN Commercial |
$240.61
|
| Rate for Payer: BCN Medicare Advantage |
$124.00
|
| Rate for Payer: Cash Price |
$233.46
|
| Rate for Payer: Cash Price |
$233.46
|
| Rate for Payer: Cofinity Commercial |
$274.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$233.46
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$124.00
|
| Rate for Payer: Healthscope Commercial |
$283.08
|
| Rate for Payer: Healthscope Whirlpool |
$291.83
|
| Rate for Payer: Humana Choice PPO Medicare |
$124.00
|
| Rate for Payer: Mclaren Commercial |
$262.65
|
| Rate for Payer: Mclaren Medicaid |
$124.00
|
| Rate for Payer: Mclaren Medicare |
$124.00
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$130.20
|
| Rate for Payer: Meridian Medicaid |
$68.10
|
| Rate for Payer: MI Amish Medical Board Commercial |
$142.60
|
| Rate for Payer: Molina Medicare/Medicaid |
$136.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$248.06
|
| Rate for Payer: Nomi Health Commercial |
$239.30
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$218.87
|
| Rate for Payer: PACE Medicare |
$117.80
|
| Rate for Payer: PACE SWMI |
$124.00
|
| Rate for Payer: PHP Commercial |
$136.40
|
| Rate for Payer: PHP Medicaid |
$66.46
|
| Rate for Payer: PHP Medicare Advantage |
$124.00
|
| Rate for Payer: Priority Health Choice Medicaid |
$64.85
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$174.32
|
| Rate for Payer: Priority Health Medicare |
$124.00
|
| Rate for Payer: Priority Health Narrow Network |
$139.46
|
| Rate for Payer: Railroad Medicare Medicare |
$124.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$256.81
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$124.00
|
| Rate for Payer: UHC Exchange |
$192.20
|
| Rate for Payer: UHC Medicaid |
$64.85
|
| Rate for Payer: UHCCP DNSP |
$124.00
|
| Rate for Payer: UHCCP Medicaid |
$64.85
|
| Rate for Payer: VA VA |
$124.00
|
|
|
HC PURAPLY AM 4X4 PER SQ CM
|
Facility
|
OP
|
$229.22
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
63600186
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$64.85 |
| Max. Negotiated Rate |
$229.22 |
| Rate for Payer: Aetna Commercial |
$206.30
|
| Rate for Payer: Aetna Medicare |
$124.00
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$155.00
|
| Rate for Payer: Amish Plain Church Group Commercial |
$155.00
|
| Rate for Payer: ASR ASR |
$222.34
|
| Rate for Payer: BCBS Complete |
$68.10
|
| Rate for Payer: BCBS MAPPO |
$124.00
|
| Rate for Payer: BCBS Trust/PPO |
$188.99
|
| Rate for Payer: BCN Commercial |
$188.99
|
| Rate for Payer: BCN Medicare Advantage |
$124.00
|
| Rate for Payer: Cash Price |
$183.38
|
| Rate for Payer: Cash Price |
$183.38
|
| Rate for Payer: Cofinity Commercial |
$215.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$183.38
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$124.00
|
| Rate for Payer: Healthscope Commercial |
$222.34
|
| Rate for Payer: Healthscope Whirlpool |
$229.22
|
| Rate for Payer: Humana Choice PPO Medicare |
$124.00
|
| Rate for Payer: Mclaren Commercial |
$206.30
|
| Rate for Payer: Mclaren Medicaid |
$124.00
|
| Rate for Payer: Mclaren Medicare |
$124.00
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$130.20
|
| Rate for Payer: Meridian Medicaid |
$68.10
|
| Rate for Payer: MI Amish Medical Board Commercial |
$142.60
|
| Rate for Payer: Molina Medicare/Medicaid |
$136.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$194.84
|
| Rate for Payer: Nomi Health Commercial |
$187.96
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$171.91
|
| Rate for Payer: PACE Medicare |
$117.80
|
| Rate for Payer: PACE SWMI |
$124.00
|
| Rate for Payer: PHP Commercial |
$136.40
|
| Rate for Payer: PHP Medicaid |
$66.46
|
| Rate for Payer: PHP Medicare Advantage |
$124.00
|
| Rate for Payer: Priority Health Choice Medicaid |
$64.85
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$174.32
|
| Rate for Payer: Priority Health Medicare |
$124.00
|
| Rate for Payer: Priority Health Narrow Network |
$139.46
|
| Rate for Payer: Railroad Medicare Medicare |
$124.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$201.71
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$124.00
|
| Rate for Payer: UHC Exchange |
$192.20
|
| Rate for Payer: UHC Medicaid |
$64.85
|
| Rate for Payer: UHCCP DNSP |
$124.00
|
| Rate for Payer: UHCCP Medicaid |
$64.85
|
| Rate for Payer: VA VA |
$124.00
|
|
|
HC PURAPLY AM 4X4 PER SQ CM
|
Facility
|
IP
|
$229.22
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
63600186
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$171.91 |
| Max. Negotiated Rate |
$229.22 |
| Rate for Payer: Aetna Commercial |
$206.30
|
| Rate for Payer: ASR ASR |
$222.34
|
| Rate for Payer: BCBS Trust/PPO |
$188.24
|
| Rate for Payer: BCN Commercial |
$188.24
|
| Rate for Payer: Cash Price |
$183.38
|
| Rate for Payer: Cofinity Commercial |
$215.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$183.38
|
| Rate for Payer: Healthscope Commercial |
$222.34
|
| Rate for Payer: Healthscope Whirlpool |
$229.22
|
| Rate for Payer: Mclaren Commercial |
$206.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$194.84
|
| Rate for Payer: Nomi Health Commercial |
$187.96
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$171.91
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$201.71
|
|
|
HC PURAPLY AM 4X4 PER SQ CM EXTRA FENESTRATED
|
Facility
|
IP
|
$229.22
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
63600184
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$171.91 |
| Max. Negotiated Rate |
$229.22 |
| Rate for Payer: Aetna Commercial |
$206.30
|
| Rate for Payer: ASR ASR |
$222.34
|
| Rate for Payer: BCBS Trust/PPO |
$188.24
|
| Rate for Payer: BCN Commercial |
$188.24
|
| Rate for Payer: Cash Price |
$183.38
|
| Rate for Payer: Cofinity Commercial |
$215.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$183.38
|
| Rate for Payer: Healthscope Commercial |
$222.34
|
| Rate for Payer: Healthscope Whirlpool |
$229.22
|
| Rate for Payer: Mclaren Commercial |
$206.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$194.84
|
| Rate for Payer: Nomi Health Commercial |
$187.96
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$171.91
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$201.71
|
|
|
HC PURAPLY AM 4X4 PER SQ CM EXTRA FENESTRATED
|
Facility
|
OP
|
$229.22
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
63600184
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$64.85 |
| Max. Negotiated Rate |
$229.22 |
| Rate for Payer: Aetna Commercial |
$206.30
|
| Rate for Payer: Aetna Medicare |
$124.00
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$155.00
|
| Rate for Payer: Amish Plain Church Group Commercial |
$155.00
|
| Rate for Payer: ASR ASR |
$222.34
|
| Rate for Payer: BCBS Complete |
$68.10
|
| Rate for Payer: BCBS MAPPO |
$124.00
|
| Rate for Payer: BCBS Trust/PPO |
$188.99
|
| Rate for Payer: BCN Commercial |
$188.99
|
| Rate for Payer: BCN Medicare Advantage |
$124.00
|
| Rate for Payer: Cash Price |
$183.38
|
| Rate for Payer: Cash Price |
$183.38
|
| Rate for Payer: Cofinity Commercial |
$215.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$183.38
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$124.00
|
| Rate for Payer: Healthscope Commercial |
$222.34
|
| Rate for Payer: Healthscope Whirlpool |
$229.22
|
| Rate for Payer: Humana Choice PPO Medicare |
$124.00
|
| Rate for Payer: Mclaren Commercial |
$206.30
|
| Rate for Payer: Mclaren Medicaid |
$124.00
|
| Rate for Payer: Mclaren Medicare |
$124.00
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$130.20
|
| Rate for Payer: Meridian Medicaid |
$68.10
|
| Rate for Payer: MI Amish Medical Board Commercial |
$142.60
|
| Rate for Payer: Molina Medicare/Medicaid |
$136.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$194.84
|
| Rate for Payer: Nomi Health Commercial |
$187.96
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$171.91
|
| Rate for Payer: PACE Medicare |
$117.80
|
| Rate for Payer: PACE SWMI |
$124.00
|
| Rate for Payer: PHP Commercial |
$136.40
|
| Rate for Payer: PHP Medicaid |
$66.46
|
| Rate for Payer: PHP Medicare Advantage |
$124.00
|
| Rate for Payer: Priority Health Choice Medicaid |
$64.85
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$174.32
|
| Rate for Payer: Priority Health Medicare |
$124.00
|
| Rate for Payer: Priority Health Narrow Network |
$139.46
|
| Rate for Payer: Railroad Medicare Medicare |
$124.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$201.71
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$124.00
|
| Rate for Payer: UHC Exchange |
$192.20
|
| Rate for Payer: UHC Medicaid |
$64.85
|
| Rate for Payer: UHCCP DNSP |
$124.00
|
| Rate for Payer: UHCCP Medicaid |
$64.85
|
| Rate for Payer: VA VA |
$124.00
|
|
|
HC PURAPLY AM 5X5 PER SQ CM
|
Facility
|
IP
|
$158.73
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
63600117
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$119.05 |
| Max. Negotiated Rate |
$158.73 |
| Rate for Payer: Aetna Commercial |
$142.86
|
| Rate for Payer: ASR ASR |
$153.97
|
| Rate for Payer: BCBS Trust/PPO |
$130.35
|
| Rate for Payer: BCN Commercial |
$130.35
|
| Rate for Payer: Cash Price |
$126.98
|
| Rate for Payer: Cofinity Commercial |
$149.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$126.98
|
| Rate for Payer: Healthscope Commercial |
$153.97
|
| Rate for Payer: Healthscope Whirlpool |
$158.73
|
| Rate for Payer: Mclaren Commercial |
$142.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$134.92
|
| Rate for Payer: Nomi Health Commercial |
$130.16
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$119.05
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$139.68
|
|
|
HC PURAPLY AM 5X5 PER SQ CM
|
Facility
|
OP
|
$158.73
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
63600117
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$64.85 |
| Max. Negotiated Rate |
$192.20 |
| Rate for Payer: Aetna Commercial |
$142.86
|
| Rate for Payer: Aetna Medicare |
$124.00
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$155.00
|
| Rate for Payer: Amish Plain Church Group Commercial |
$155.00
|
| Rate for Payer: ASR ASR |
$153.97
|
| Rate for Payer: BCBS Complete |
$68.10
|
| Rate for Payer: BCBS MAPPO |
$124.00
|
| Rate for Payer: BCBS Trust/PPO |
$130.87
|
| Rate for Payer: BCN Commercial |
$130.87
|
| Rate for Payer: BCN Medicare Advantage |
$124.00
|
| Rate for Payer: Cash Price |
$126.98
|
| Rate for Payer: Cash Price |
$126.98
|
| Rate for Payer: Cofinity Commercial |
$149.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$126.98
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$124.00
|
| Rate for Payer: Healthscope Commercial |
$153.97
|
| Rate for Payer: Healthscope Whirlpool |
$158.73
|
| Rate for Payer: Humana Choice PPO Medicare |
$124.00
|
| Rate for Payer: Mclaren Commercial |
$142.86
|
| Rate for Payer: Mclaren Medicaid |
$124.00
|
| Rate for Payer: Mclaren Medicare |
$124.00
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$130.20
|
| Rate for Payer: Meridian Medicaid |
$68.10
|
| Rate for Payer: MI Amish Medical Board Commercial |
$142.60
|
| Rate for Payer: Molina Medicare/Medicaid |
$136.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$134.92
|
| Rate for Payer: Nomi Health Commercial |
$130.16
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$119.05
|
| Rate for Payer: PACE Medicare |
$117.80
|
| Rate for Payer: PACE SWMI |
$124.00
|
| Rate for Payer: PHP Commercial |
$136.40
|
| Rate for Payer: PHP Medicaid |
$66.46
|
| Rate for Payer: PHP Medicare Advantage |
$124.00
|
| Rate for Payer: Priority Health Choice Medicaid |
$64.85
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$174.32
|
| Rate for Payer: Priority Health Medicare |
$124.00
|
| Rate for Payer: Priority Health Narrow Network |
$139.46
|
| Rate for Payer: Railroad Medicare Medicare |
$124.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$139.68
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$124.00
|
| Rate for Payer: UHC Exchange |
$192.20
|
| Rate for Payer: UHC Medicaid |
$64.85
|
| Rate for Payer: UHCCP DNSP |
$124.00
|
| Rate for Payer: UHCCP Medicaid |
$64.85
|
| Rate for Payer: VA VA |
$124.00
|
|
|
HC PURAPLY AM 6X9 PER SQ CM
|
Facility
|
OP
|
$208.15
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
63600118
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$64.85 |
| Max. Negotiated Rate |
$208.15 |
| Rate for Payer: Aetna Commercial |
$187.34
|
| Rate for Payer: Aetna Medicare |
$124.00
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$155.00
|
| Rate for Payer: Amish Plain Church Group Commercial |
$155.00
|
| Rate for Payer: ASR ASR |
$201.91
|
| Rate for Payer: BCBS Complete |
$68.10
|
| Rate for Payer: BCBS MAPPO |
$124.00
|
| Rate for Payer: BCBS Trust/PPO |
$171.62
|
| Rate for Payer: BCN Commercial |
$171.62
|
| Rate for Payer: BCN Medicare Advantage |
$124.00
|
| Rate for Payer: Cash Price |
$166.52
|
| Rate for Payer: Cash Price |
$166.52
|
| Rate for Payer: Cofinity Commercial |
$195.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$166.52
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$124.00
|
| Rate for Payer: Healthscope Commercial |
$201.91
|
| Rate for Payer: Healthscope Whirlpool |
$208.15
|
| Rate for Payer: Humana Choice PPO Medicare |
$124.00
|
| Rate for Payer: Mclaren Commercial |
$187.34
|
| Rate for Payer: Mclaren Medicaid |
$124.00
|
| Rate for Payer: Mclaren Medicare |
$124.00
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$130.20
|
| Rate for Payer: Meridian Medicaid |
$68.10
|
| Rate for Payer: MI Amish Medical Board Commercial |
$142.60
|
| Rate for Payer: Molina Medicare/Medicaid |
$136.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$176.93
|
| Rate for Payer: Nomi Health Commercial |
$170.68
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$156.11
|
| Rate for Payer: PACE Medicare |
$117.80
|
| Rate for Payer: PACE SWMI |
$124.00
|
| Rate for Payer: PHP Commercial |
$136.40
|
| Rate for Payer: PHP Medicaid |
$66.46
|
| Rate for Payer: PHP Medicare Advantage |
$124.00
|
| Rate for Payer: Priority Health Choice Medicaid |
$64.85
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$174.32
|
| Rate for Payer: Priority Health Medicare |
$124.00
|
| Rate for Payer: Priority Health Narrow Network |
$139.46
|
| Rate for Payer: Railroad Medicare Medicare |
$124.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$183.17
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$124.00
|
| Rate for Payer: UHC Exchange |
$192.20
|
| Rate for Payer: UHC Medicaid |
$64.85
|
| Rate for Payer: UHCCP DNSP |
$124.00
|
| Rate for Payer: UHCCP Medicaid |
$64.85
|
| Rate for Payer: VA VA |
$124.00
|
|
|
HC PURAPLY AM 6X9 PER SQ CM
|
Facility
|
IP
|
$208.15
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
63600118
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$156.11 |
| Max. Negotiated Rate |
$208.15 |
| Rate for Payer: Aetna Commercial |
$187.34
|
| Rate for Payer: ASR ASR |
$201.91
|
| Rate for Payer: BCBS Trust/PPO |
$170.93
|
| Rate for Payer: BCN Commercial |
$170.93
|
| Rate for Payer: Cash Price |
$166.52
|
| Rate for Payer: Cofinity Commercial |
$195.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$166.52
|
| Rate for Payer: Healthscope Commercial |
$201.91
|
| Rate for Payer: Healthscope Whirlpool |
$208.15
|
| Rate for Payer: Mclaren Commercial |
$187.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$176.93
|
| Rate for Payer: Nomi Health Commercial |
$170.68
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$156.11
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$183.17
|
|
|
HC PURAPLY XT PER SQ CM
|
Facility
|
IP
|
$138.72
|
|
|
Service Code
|
HCPCS Q4197
|
| Hospital Charge Code |
63600245
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$104.04 |
| Max. Negotiated Rate |
$138.72 |
| Rate for Payer: Aetna Commercial |
$124.85
|
| Rate for Payer: ASR ASR |
$134.56
|
| Rate for Payer: BCBS Trust/PPO |
$113.92
|
| Rate for Payer: BCN Commercial |
$113.92
|
| Rate for Payer: Cash Price |
$110.98
|
| Rate for Payer: Cofinity Commercial |
$130.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$110.98
|
| Rate for Payer: Healthscope Commercial |
$134.56
|
| Rate for Payer: Healthscope Whirlpool |
$138.72
|
| Rate for Payer: Mclaren Commercial |
$124.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$117.91
|
| Rate for Payer: Nomi Health Commercial |
$113.75
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$104.04
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$122.07
|
|
|
HC PURAPLY XT PER SQ CM
|
Facility
|
OP
|
$138.72
|
|
|
Service Code
|
HCPCS Q4197
|
| Hospital Charge Code |
63600245
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$64.85 |
| Max. Negotiated Rate |
$255.00 |
| Rate for Payer: Aetna Commercial |
$124.85
|
| Rate for Payer: Aetna Medicare |
$124.00
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$155.00
|
| Rate for Payer: Amish Plain Church Group Commercial |
$155.00
|
| Rate for Payer: ASR ASR |
$134.56
|
| Rate for Payer: BCBS Complete |
$68.10
|
| Rate for Payer: BCBS MAPPO |
$124.00
|
| Rate for Payer: BCBS Trust/PPO |
$114.37
|
| Rate for Payer: BCN Commercial |
$114.37
|
| Rate for Payer: BCN Medicare Advantage |
$124.00
|
| Rate for Payer: Cash Price |
$110.98
|
| Rate for Payer: Cash Price |
$110.98
|
| Rate for Payer: Cofinity Commercial |
$130.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$110.98
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$124.00
|
| Rate for Payer: Healthscope Commercial |
$134.56
|
| Rate for Payer: Healthscope Whirlpool |
$138.72
|
| Rate for Payer: Humana Choice PPO Medicare |
$124.00
|
| Rate for Payer: Mclaren Commercial |
$124.85
|
| Rate for Payer: Mclaren Medicaid |
$124.00
|
| Rate for Payer: Mclaren Medicare |
$124.00
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$130.20
|
| Rate for Payer: Meridian Medicaid |
$68.10
|
| Rate for Payer: MI Amish Medical Board Commercial |
$142.60
|
| Rate for Payer: Molina Medicare/Medicaid |
$136.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$117.91
|
| Rate for Payer: Nomi Health Commercial |
$113.75
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$104.04
|
| Rate for Payer: PACE Medicare |
$117.80
|
| Rate for Payer: PACE SWMI |
$124.00
|
| Rate for Payer: PHP Commercial |
$136.40
|
| Rate for Payer: PHP Medicaid |
$66.46
|
| Rate for Payer: PHP Medicare Advantage |
$124.00
|
| Rate for Payer: Priority Health Choice Medicaid |
$64.85
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$255.00
|
| Rate for Payer: Priority Health Medicare |
$124.00
|
| Rate for Payer: Priority Health Narrow Network |
$204.00
|
| Rate for Payer: Railroad Medicare Medicare |
$124.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$122.07
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$124.00
|
| Rate for Payer: UHC Exchange |
$192.20
|
| Rate for Payer: UHC Medicaid |
$64.85
|
| Rate for Payer: UHCCP DNSP |
$124.00
|
| Rate for Payer: UHCCP Medicaid |
$64.85
|
| Rate for Payer: VA VA |
$124.00
|
|
|
HC PURE TONE AUDIOMETRY AIR
|
Facility
|
OP
|
$169.49
|
|
|
Service Code
|
CPT 92552
|
| Hospital Charge Code |
47100009
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$69.33 |
| Max. Negotiated Rate |
$205.48 |
| Rate for Payer: Aetna Commercial |
$152.54
|
| Rate for Payer: Aetna Medicare |
$132.57
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$165.71
|
| Rate for Payer: Amish Plain Church Group Commercial |
$165.71
|
| Rate for Payer: ASR ASR |
$164.41
|
| Rate for Payer: BCBS Complete |
$72.81
|
| Rate for Payer: BCBS MAPPO |
$132.57
|
| Rate for Payer: BCBS Trust/PPO |
$139.74
|
| Rate for Payer: BCN Commercial |
$139.74
|
| Rate for Payer: BCN Medicare Advantage |
$132.57
|
| Rate for Payer: Cash Price |
$135.59
|
| Rate for Payer: Cash Price |
$135.59
|
| Rate for Payer: Cofinity Commercial |
$159.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$135.59
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$132.57
|
| Rate for Payer: Healthscope Commercial |
$164.41
|
| Rate for Payer: Healthscope Whirlpool |
$169.49
|
| Rate for Payer: Humana Choice PPO Medicare |
$132.57
|
| Rate for Payer: Mclaren Commercial |
$152.54
|
| Rate for Payer: Mclaren Medicaid |
$132.57
|
| Rate for Payer: Mclaren Medicare |
$132.57
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$139.20
|
| Rate for Payer: Meridian Medicaid |
$72.81
|
| Rate for Payer: MI Amish Medical Board Commercial |
$152.46
|
| Rate for Payer: Molina Medicare/Medicaid |
$145.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$144.07
|
| Rate for Payer: Nomi Health Commercial |
$138.98
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$127.12
|
| Rate for Payer: PACE Medicare |
$125.94
|
| Rate for Payer: PACE SWMI |
$132.57
|
| Rate for Payer: PHP Commercial |
$145.83
|
| Rate for Payer: PHP Medicaid |
$71.06
|
| Rate for Payer: PHP Medicare Advantage |
$132.57
|
| Rate for Payer: Priority Health Choice Medicaid |
$69.33
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$148.51
|
| Rate for Payer: Priority Health Medicare |
$132.57
|
| Rate for Payer: Priority Health Narrow Network |
$118.81
|
| Rate for Payer: Railroad Medicare Medicare |
$132.57
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$149.15
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$132.57
|
| Rate for Payer: UHC Exchange |
$205.48
|
| Rate for Payer: UHC Medicaid |
$69.33
|
| Rate for Payer: UHCCP DNSP |
$132.57
|
| Rate for Payer: UHCCP Medicaid |
$69.33
|
| Rate for Payer: VA VA |
$132.57
|
|
|
HC PURE TONE AUDIOMETRY AIR
|
Facility
|
IP
|
$169.49
|
|
|
Service Code
|
CPT 92552
|
| Hospital Charge Code |
47100009
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$127.12 |
| Max. Negotiated Rate |
$169.49 |
| Rate for Payer: Aetna Commercial |
$152.54
|
| Rate for Payer: ASR ASR |
$164.41
|
| Rate for Payer: BCBS Trust/PPO |
$139.19
|
| Rate for Payer: BCN Commercial |
$139.19
|
| Rate for Payer: Cash Price |
$135.59
|
| Rate for Payer: Cofinity Commercial |
$159.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$135.59
|
| Rate for Payer: Healthscope Commercial |
$164.41
|
| Rate for Payer: Healthscope Whirlpool |
$169.49
|
| Rate for Payer: Mclaren Commercial |
$152.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$144.07
|
| Rate for Payer: Nomi Health Commercial |
$138.98
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$127.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$149.15
|
|
|
HC PV JAK2V617F
|
Facility
|
IP
|
$336.10
|
|
|
Service Code
|
CPT 81270
|
| Hospital Charge Code |
31000147
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$252.07 |
| Max. Negotiated Rate |
$336.10 |
| Rate for Payer: Aetna Commercial |
$302.49
|
| Rate for Payer: ASR ASR |
$326.02
|
| Rate for Payer: BCBS Trust/PPO |
$276.01
|
| Rate for Payer: BCN Commercial |
$276.01
|
| Rate for Payer: Cash Price |
$268.88
|
| Rate for Payer: Cofinity Commercial |
$315.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$268.88
|
| Rate for Payer: Healthscope Commercial |
$326.02
|
| Rate for Payer: Healthscope Whirlpool |
$336.10
|
| Rate for Payer: Mclaren Commercial |
$302.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$285.69
|
| Rate for Payer: Nomi Health Commercial |
$275.60
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$252.07
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$295.77
|
|
