|
HC PURAPLY AM 2X2 PER SQ CM
|
Facility
|
IP
|
$512.07
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
63600115
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$332.85 |
| Max. Negotiated Rate |
$512.07 |
| Rate for Payer: Aetna Commercial |
$460.86
|
| Rate for Payer: ASR ASR |
$496.71
|
| Rate for Payer: ASR Commercial |
$496.71
|
| Rate for Payer: BCBS Trust/PPO |
$417.29
|
| Rate for Payer: BCN Commercial |
$397.01
|
| Rate for Payer: Cash Price |
$409.66
|
| Rate for Payer: Cofinity Commercial |
$481.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$409.66
|
| Rate for Payer: Healthscope Commercial |
$512.07
|
| Rate for Payer: Healthscope Whirlpool |
$496.71
|
| Rate for Payer: Mclaren Commercial |
$460.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$435.26
|
| Rate for Payer: Nomi Health Commercial |
$419.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$332.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$450.62
|
|
|
HC PURAPLY AM 2X2 PER SQ CM
|
Facility
|
OP
|
$512.07
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
63600115
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$204.83 |
| Max. Negotiated Rate |
$512.07 |
| Rate for Payer: Aetna Commercial |
$460.86
|
| Rate for Payer: Aetna Medicare |
$256.04
|
| Rate for Payer: ASR ASR |
$496.71
|
| Rate for Payer: ASR Commercial |
$496.71
|
| Rate for Payer: BCBS Complete |
$204.83
|
| Rate for Payer: BCBS Trust/PPO |
$419.33
|
| Rate for Payer: BCN Commercial |
$397.01
|
| Rate for Payer: Cash Price |
$409.66
|
| Rate for Payer: Cofinity Commercial |
$481.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$409.66
|
| Rate for Payer: Healthscope Commercial |
$512.07
|
| Rate for Payer: Healthscope Whirlpool |
$496.71
|
| Rate for Payer: Mclaren Commercial |
$460.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$435.26
|
| Rate for Payer: Nomi Health Commercial |
$419.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$332.85
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$448.68
|
| Rate for Payer: Priority Health Narrow Network |
$358.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$450.62
|
|
|
HC PURAPLY AM 2X4 PER SQ CM
|
Facility
|
IP
|
$324.31
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
63600116
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$210.80 |
| Max. Negotiated Rate |
$324.31 |
| Rate for Payer: Aetna Commercial |
$291.88
|
| Rate for Payer: ASR ASR |
$314.58
|
| Rate for Payer: ASR Commercial |
$314.58
|
| Rate for Payer: BCBS Trust/PPO |
$264.28
|
| Rate for Payer: BCN Commercial |
$251.44
|
| Rate for Payer: Cash Price |
$259.45
|
| Rate for Payer: Cofinity Commercial |
$304.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$259.45
|
| Rate for Payer: Healthscope Commercial |
$324.31
|
| Rate for Payer: Healthscope Whirlpool |
$314.58
|
| Rate for Payer: Mclaren Commercial |
$291.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$275.66
|
| Rate for Payer: Nomi Health Commercial |
$265.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$210.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$285.39
|
|
|
HC PURAPLY AM 2X4 PER SQ CM
|
Facility
|
OP
|
$324.31
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
63600116
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$129.72 |
| Max. Negotiated Rate |
$324.31 |
| Rate for Payer: Aetna Commercial |
$291.88
|
| Rate for Payer: Aetna Medicare |
$162.16
|
| Rate for Payer: ASR ASR |
$314.58
|
| Rate for Payer: ASR Commercial |
$314.58
|
| Rate for Payer: BCBS Complete |
$129.72
|
| Rate for Payer: BCBS Trust/PPO |
$265.58
|
| Rate for Payer: BCN Commercial |
$251.44
|
| Rate for Payer: Cash Price |
$259.45
|
| Rate for Payer: Cofinity Commercial |
$304.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$259.45
|
| Rate for Payer: Healthscope Commercial |
$324.31
|
| Rate for Payer: Healthscope Whirlpool |
$314.58
|
| Rate for Payer: Mclaren Commercial |
$291.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$275.66
|
| Rate for Payer: Nomi Health Commercial |
$265.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$210.80
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$284.16
|
| Rate for Payer: Priority Health Narrow Network |
$227.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$285.39
|
|
|
HC PURAPLY AM 3X4 PER SQ CM
|
Facility
|
IP
|
$270.94
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
63600185
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$176.11 |
| Max. Negotiated Rate |
$270.94 |
| Rate for Payer: Aetna Commercial |
$243.85
|
| Rate for Payer: ASR ASR |
$262.81
|
| Rate for Payer: ASR Commercial |
$262.81
|
| Rate for Payer: BCBS Trust/PPO |
$220.79
|
| Rate for Payer: BCN Commercial |
$210.06
|
| Rate for Payer: Cash Price |
$216.75
|
| Rate for Payer: Cofinity Commercial |
$254.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$216.75
|
| Rate for Payer: Healthscope Commercial |
$270.94
|
| Rate for Payer: Healthscope Whirlpool |
$262.81
|
| Rate for Payer: Mclaren Commercial |
$243.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$230.30
|
| Rate for Payer: Nomi Health Commercial |
$222.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$176.11
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$238.43
|
|
|
HC PURAPLY AM 3X4 PER SQ CM
|
Facility
|
OP
|
$270.94
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
63600185
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$108.38 |
| Max. Negotiated Rate |
$270.94 |
| Rate for Payer: Aetna Commercial |
$243.85
|
| Rate for Payer: Aetna Medicare |
$135.47
|
| Rate for Payer: ASR ASR |
$262.81
|
| Rate for Payer: ASR Commercial |
$262.81
|
| Rate for Payer: BCBS Complete |
$108.38
|
| Rate for Payer: BCBS Trust/PPO |
$221.87
|
| Rate for Payer: BCN Commercial |
$210.06
|
| Rate for Payer: Cash Price |
$216.75
|
| Rate for Payer: Cofinity Commercial |
$254.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$216.75
|
| Rate for Payer: Healthscope Commercial |
$270.94
|
| Rate for Payer: Healthscope Whirlpool |
$262.81
|
| Rate for Payer: Mclaren Commercial |
$243.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$230.30
|
| Rate for Payer: Nomi Health Commercial |
$222.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$176.11
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$237.40
|
| Rate for Payer: Priority Health Narrow Network |
$189.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$238.43
|
|
|
HC PURAPLY AM 4X3 PER SQ CM EXTRA FENESTRATED
|
Facility
|
IP
|
$286.11
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
63600183
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$185.97 |
| Max. Negotiated Rate |
$286.11 |
| Rate for Payer: Aetna Commercial |
$257.50
|
| Rate for Payer: ASR ASR |
$277.53
|
| Rate for Payer: ASR Commercial |
$277.53
|
| Rate for Payer: BCBS Trust/PPO |
$233.15
|
| Rate for Payer: BCN Commercial |
$221.82
|
| Rate for Payer: Cash Price |
$228.89
|
| Rate for Payer: Cofinity Commercial |
$268.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$228.89
|
| Rate for Payer: Healthscope Commercial |
$286.11
|
| Rate for Payer: Healthscope Whirlpool |
$277.53
|
| Rate for Payer: Mclaren Commercial |
$257.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$243.19
|
| Rate for Payer: Nomi Health Commercial |
$234.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$185.97
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$251.78
|
|
|
HC PURAPLY AM 4X3 PER SQ CM EXTRA FENESTRATED
|
Facility
|
OP
|
$286.11
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
63600183
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$114.44 |
| Max. Negotiated Rate |
$286.11 |
| Rate for Payer: Aetna Commercial |
$257.50
|
| Rate for Payer: Aetna Medicare |
$143.06
|
| Rate for Payer: ASR ASR |
$277.53
|
| Rate for Payer: ASR Commercial |
$277.53
|
| Rate for Payer: BCBS Complete |
$114.44
|
| Rate for Payer: BCBS Trust/PPO |
$234.30
|
| Rate for Payer: BCN Commercial |
$221.82
|
| Rate for Payer: Cash Price |
$228.89
|
| Rate for Payer: Cofinity Commercial |
$268.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$228.89
|
| Rate for Payer: Healthscope Commercial |
$286.11
|
| Rate for Payer: Healthscope Whirlpool |
$277.53
|
| Rate for Payer: Mclaren Commercial |
$257.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$243.19
|
| Rate for Payer: Nomi Health Commercial |
$234.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$185.97
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$250.69
|
| Rate for Payer: Priority Health Narrow Network |
$200.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$251.78
|
|
|
HC PURAPLY AM 4X4 PER SQ CM
|
Facility
|
IP
|
$224.73
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
63600186
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$146.07 |
| Max. Negotiated Rate |
$224.73 |
| Rate for Payer: Aetna Commercial |
$202.26
|
| Rate for Payer: ASR ASR |
$217.99
|
| Rate for Payer: ASR Commercial |
$217.99
|
| Rate for Payer: BCBS Trust/PPO |
$183.13
|
| Rate for Payer: BCN Commercial |
$174.23
|
| Rate for Payer: Cash Price |
$179.78
|
| Rate for Payer: Cofinity Commercial |
$211.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$179.78
|
| Rate for Payer: Healthscope Commercial |
$224.73
|
| Rate for Payer: Healthscope Whirlpool |
$217.99
|
| Rate for Payer: Mclaren Commercial |
$202.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$191.02
|
| Rate for Payer: Nomi Health Commercial |
$184.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$146.07
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$197.76
|
|
|
HC PURAPLY AM 4X4 PER SQ CM
|
Facility
|
OP
|
$224.73
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
63600186
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$89.89 |
| Max. Negotiated Rate |
$224.73 |
| Rate for Payer: Aetna Commercial |
$202.26
|
| Rate for Payer: Aetna Medicare |
$112.36
|
| Rate for Payer: ASR ASR |
$217.99
|
| Rate for Payer: ASR Commercial |
$217.99
|
| Rate for Payer: BCBS Complete |
$89.89
|
| Rate for Payer: BCBS Trust/PPO |
$184.03
|
| Rate for Payer: BCN Commercial |
$174.23
|
| Rate for Payer: Cash Price |
$179.78
|
| Rate for Payer: Cofinity Commercial |
$211.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$179.78
|
| Rate for Payer: Healthscope Commercial |
$224.73
|
| Rate for Payer: Healthscope Whirlpool |
$217.99
|
| Rate for Payer: Mclaren Commercial |
$202.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$191.02
|
| Rate for Payer: Nomi Health Commercial |
$184.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$146.07
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$196.91
|
| Rate for Payer: Priority Health Narrow Network |
$157.54
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$197.76
|
|
|
HC PURAPLY AM 4X4 PER SQ CM EXTRA FENESTRATED
|
Facility
|
OP
|
$224.73
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
63600184
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$89.89 |
| Max. Negotiated Rate |
$224.73 |
| Rate for Payer: Aetna Commercial |
$202.26
|
| Rate for Payer: Aetna Medicare |
$112.36
|
| Rate for Payer: ASR ASR |
$217.99
|
| Rate for Payer: ASR Commercial |
$217.99
|
| Rate for Payer: BCBS Complete |
$89.89
|
| Rate for Payer: BCBS Trust/PPO |
$184.03
|
| Rate for Payer: BCN Commercial |
$174.23
|
| Rate for Payer: Cash Price |
$179.78
|
| Rate for Payer: Cofinity Commercial |
$211.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$179.78
|
| Rate for Payer: Healthscope Commercial |
$224.73
|
| Rate for Payer: Healthscope Whirlpool |
$217.99
|
| Rate for Payer: Mclaren Commercial |
$202.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$191.02
|
| Rate for Payer: Nomi Health Commercial |
$184.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$146.07
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$196.91
|
| Rate for Payer: Priority Health Narrow Network |
$157.54
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$197.76
|
|
|
HC PURAPLY AM 4X4 PER SQ CM EXTRA FENESTRATED
|
Facility
|
IP
|
$224.73
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
63600184
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$146.07 |
| Max. Negotiated Rate |
$224.73 |
| Rate for Payer: Aetna Commercial |
$202.26
|
| Rate for Payer: ASR ASR |
$217.99
|
| Rate for Payer: ASR Commercial |
$217.99
|
| Rate for Payer: BCBS Trust/PPO |
$183.13
|
| Rate for Payer: BCN Commercial |
$174.23
|
| Rate for Payer: Cash Price |
$179.78
|
| Rate for Payer: Cofinity Commercial |
$211.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$179.78
|
| Rate for Payer: Healthscope Commercial |
$224.73
|
| Rate for Payer: Healthscope Whirlpool |
$217.99
|
| Rate for Payer: Mclaren Commercial |
$202.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$191.02
|
| Rate for Payer: Nomi Health Commercial |
$184.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$146.07
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$197.76
|
|
|
HC PURAPLY AM 5X5 PER SQ CM
|
Facility
|
IP
|
$155.62
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
63600117
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$101.15 |
| Max. Negotiated Rate |
$155.62 |
| Rate for Payer: Aetna Commercial |
$140.06
|
| Rate for Payer: ASR ASR |
$150.95
|
| Rate for Payer: ASR Commercial |
$150.95
|
| Rate for Payer: BCBS Trust/PPO |
$126.81
|
| Rate for Payer: BCN Commercial |
$120.65
|
| Rate for Payer: Cash Price |
$124.50
|
| Rate for Payer: Cofinity Commercial |
$146.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$124.50
|
| Rate for Payer: Healthscope Commercial |
$155.62
|
| Rate for Payer: Healthscope Whirlpool |
$150.95
|
| Rate for Payer: Mclaren Commercial |
$140.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$132.28
|
| Rate for Payer: Nomi Health Commercial |
$127.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$101.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$136.95
|
|
|
HC PURAPLY AM 5X5 PER SQ CM
|
Facility
|
OP
|
$155.62
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
63600117
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$62.25 |
| Max. Negotiated Rate |
$155.62 |
| Rate for Payer: Aetna Commercial |
$140.06
|
| Rate for Payer: Aetna Medicare |
$77.81
|
| Rate for Payer: ASR ASR |
$150.95
|
| Rate for Payer: ASR Commercial |
$150.95
|
| Rate for Payer: BCBS Complete |
$62.25
|
| Rate for Payer: BCBS Trust/PPO |
$127.44
|
| Rate for Payer: BCN Commercial |
$120.65
|
| Rate for Payer: Cash Price |
$124.50
|
| Rate for Payer: Cofinity Commercial |
$146.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$124.50
|
| Rate for Payer: Healthscope Commercial |
$155.62
|
| Rate for Payer: Healthscope Whirlpool |
$150.95
|
| Rate for Payer: Mclaren Commercial |
$140.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$132.28
|
| Rate for Payer: Nomi Health Commercial |
$127.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$101.15
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$136.35
|
| Rate for Payer: Priority Health Narrow Network |
$109.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$136.95
|
|
|
HC PURAPLY AM 6X9 PER SQ CM
|
Facility
|
IP
|
$204.07
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
63600118
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$132.65 |
| Max. Negotiated Rate |
$204.07 |
| Rate for Payer: Aetna Commercial |
$183.66
|
| Rate for Payer: ASR ASR |
$197.95
|
| Rate for Payer: ASR Commercial |
$197.95
|
| Rate for Payer: BCBS Trust/PPO |
$166.30
|
| Rate for Payer: BCN Commercial |
$158.22
|
| Rate for Payer: Cash Price |
$163.26
|
| Rate for Payer: Cofinity Commercial |
$191.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$163.26
|
| Rate for Payer: Healthscope Commercial |
$204.07
|
| Rate for Payer: Healthscope Whirlpool |
$197.95
|
| Rate for Payer: Mclaren Commercial |
$183.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$173.46
|
| Rate for Payer: Nomi Health Commercial |
$167.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$132.65
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$179.58
|
|
|
HC PURAPLY AM 6X9 PER SQ CM
|
Facility
|
OP
|
$204.07
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
63600118
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$81.63 |
| Max. Negotiated Rate |
$204.07 |
| Rate for Payer: Aetna Commercial |
$183.66
|
| Rate for Payer: Aetna Medicare |
$102.03
|
| Rate for Payer: ASR ASR |
$197.95
|
| Rate for Payer: ASR Commercial |
$197.95
|
| Rate for Payer: BCBS Complete |
$81.63
|
| Rate for Payer: BCBS Trust/PPO |
$167.11
|
| Rate for Payer: BCN Commercial |
$158.22
|
| Rate for Payer: Cash Price |
$163.26
|
| Rate for Payer: Cofinity Commercial |
$191.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$163.26
|
| Rate for Payer: Healthscope Commercial |
$204.07
|
| Rate for Payer: Healthscope Whirlpool |
$197.95
|
| Rate for Payer: Mclaren Commercial |
$183.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$173.46
|
| Rate for Payer: Nomi Health Commercial |
$167.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$132.65
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$178.81
|
| Rate for Payer: Priority Health Narrow Network |
$143.05
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$179.58
|
|
|
HC PURAPLY XT PER SQ CM
|
Facility
|
IP
|
$136.00
|
|
|
Service Code
|
HCPCS Q4197
|
| Hospital Charge Code |
63600245
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$88.40 |
| Max. Negotiated Rate |
$136.00 |
| Rate for Payer: Aetna Commercial |
$122.40
|
| Rate for Payer: ASR ASR |
$131.92
|
| Rate for Payer: ASR Commercial |
$131.92
|
| Rate for Payer: BCBS Trust/PPO |
$110.83
|
| Rate for Payer: BCN Commercial |
$105.44
|
| Rate for Payer: Cash Price |
$108.80
|
| Rate for Payer: Cofinity Commercial |
$127.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$108.80
|
| Rate for Payer: Healthscope Commercial |
$136.00
|
| Rate for Payer: Healthscope Whirlpool |
$131.92
|
| Rate for Payer: Mclaren Commercial |
$122.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$115.60
|
| Rate for Payer: Nomi Health Commercial |
$111.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$88.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$119.68
|
|
|
HC PURAPLY XT PER SQ CM
|
Facility
|
OP
|
$136.00
|
|
|
Service Code
|
HCPCS Q4197
|
| Hospital Charge Code |
63600245
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$54.40 |
| Max. Negotiated Rate |
$136.00 |
| Rate for Payer: Aetna Commercial |
$122.40
|
| Rate for Payer: Aetna Medicare |
$68.00
|
| Rate for Payer: ASR ASR |
$131.92
|
| Rate for Payer: ASR Commercial |
$131.92
|
| Rate for Payer: BCBS Complete |
$54.40
|
| Rate for Payer: BCBS Trust/PPO |
$111.37
|
| Rate for Payer: BCN Commercial |
$105.44
|
| Rate for Payer: Cash Price |
$108.80
|
| Rate for Payer: Cofinity Commercial |
$127.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$108.80
|
| Rate for Payer: Healthscope Commercial |
$136.00
|
| Rate for Payer: Healthscope Whirlpool |
$131.92
|
| Rate for Payer: Mclaren Commercial |
$122.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$115.60
|
| Rate for Payer: Nomi Health Commercial |
$111.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$88.40
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$119.16
|
| Rate for Payer: Priority Health Narrow Network |
$95.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$119.68
|
|
|
HC PURE TONE AUDIOMETRY AIR
|
Facility
|
IP
|
$166.17
|
|
|
Service Code
|
CPT 92552
|
| Hospital Charge Code |
47100009
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$108.01 |
| Max. Negotiated Rate |
$166.17 |
| Rate for Payer: Aetna Commercial |
$149.55
|
| Rate for Payer: ASR ASR |
$161.18
|
| Rate for Payer: ASR Commercial |
$161.18
|
| Rate for Payer: BCBS Trust/PPO |
$135.41
|
| Rate for Payer: BCN Commercial |
$128.83
|
| Rate for Payer: Cash Price |
$132.94
|
| Rate for Payer: Cofinity Commercial |
$156.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$132.94
|
| Rate for Payer: Healthscope Commercial |
$166.17
|
| Rate for Payer: Healthscope Whirlpool |
$161.18
|
| Rate for Payer: Mclaren Commercial |
$149.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$141.24
|
| Rate for Payer: Nomi Health Commercial |
$136.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$108.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$146.23
|
|
|
HC PURE TONE AUDIOMETRY AIR
|
Facility
|
OP
|
$166.17
|
|
|
Service Code
|
CPT 92552
|
| Hospital Charge Code |
47100009
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$67.38 |
| Max. Negotiated Rate |
$194.85 |
| Rate for Payer: Aetna Commercial |
$149.55
|
| Rate for Payer: Aetna Medicare |
$125.71
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$157.14
|
| Rate for Payer: Amish Plain Church Group Commercial |
$157.14
|
| Rate for Payer: ASR ASR |
$161.18
|
| Rate for Payer: ASR Commercial |
$161.18
|
| Rate for Payer: BCBS Complete |
$70.75
|
| Rate for Payer: BCBS MAPPO |
$125.71
|
| Rate for Payer: BCBS Trust/PPO |
$136.08
|
| Rate for Payer: BCN Commercial |
$128.83
|
| Rate for Payer: BCN Medicare Advantage |
$125.71
|
| Rate for Payer: Cash Price |
$132.94
|
| Rate for Payer: Cash Price |
$132.94
|
| Rate for Payer: Cofinity Commercial |
$156.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$132.94
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$125.71
|
| Rate for Payer: Healthscope Commercial |
$166.17
|
| Rate for Payer: Healthscope Whirlpool |
$161.18
|
| Rate for Payer: Humana Choice PPO Medicare |
$125.71
|
| Rate for Payer: Mclaren Commercial |
$149.55
|
| Rate for Payer: Mclaren Medicaid |
$67.38
|
| Rate for Payer: Mclaren Medicare |
$125.71
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$132.00
|
| Rate for Payer: Meridian Medicaid |
$70.75
|
| Rate for Payer: MI Amish Medical Board Commercial |
$144.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$141.24
|
| Rate for Payer: Nomi Health Commercial |
$136.26
|
| Rate for Payer: PACE Medicare |
$119.42
|
| Rate for Payer: PACE SWMI |
$125.71
|
| Rate for Payer: PHP Commercial |
$138.28
|
| Rate for Payer: PHP Medicaid |
$67.38
|
| Rate for Payer: PHP Medicare Advantage |
$125.71
|
| Rate for Payer: Priority Health Choice Medicaid |
$67.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$108.01
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$145.60
|
| Rate for Payer: Priority Health Medicare |
$125.71
|
| Rate for Payer: Priority Health Narrow Network |
$116.49
|
| Rate for Payer: Railroad Medicare Medicare |
$125.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$146.23
|
| Rate for Payer: UHC Dual Complete DSNP |
$125.71
|
| Rate for Payer: UHC Exchange |
$194.85
|
| Rate for Payer: UHC Medicare Advantage |
$125.71
|
| Rate for Payer: UHCCP DNSP |
$125.71
|
| Rate for Payer: UHCCP Medicaid |
$67.38
|
| Rate for Payer: VA VA |
$125.71
|
|
|
HC PV JAK2V617F
|
Facility
|
OP
|
$329.51
|
|
|
Service Code
|
CPT 81270
|
| Hospital Charge Code |
31000147
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$49.13 |
| Max. Negotiated Rate |
$329.51 |
| Rate for Payer: Aetna Commercial |
$296.56
|
| Rate for Payer: Aetna Medicare |
$91.66
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$114.58
|
| Rate for Payer: Amish Plain Church Group Commercial |
$114.58
|
| Rate for Payer: ASR ASR |
$319.62
|
| Rate for Payer: ASR Commercial |
$319.62
|
| Rate for Payer: BCBS Complete |
$51.59
|
| Rate for Payer: BCBS MAPPO |
$91.66
|
| Rate for Payer: BCBS Trust/PPO |
$269.84
|
| Rate for Payer: BCN Commercial |
$255.47
|
| Rate for Payer: BCN Medicare Advantage |
$91.66
|
| Rate for Payer: Cash Price |
$263.61
|
| Rate for Payer: Cash Price |
$263.61
|
| Rate for Payer: Cofinity Commercial |
$309.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$263.61
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$91.66
|
| Rate for Payer: Healthscope Commercial |
$329.51
|
| Rate for Payer: Healthscope Whirlpool |
$319.62
|
| Rate for Payer: Humana Choice PPO Medicare |
$91.66
|
| Rate for Payer: Mclaren Commercial |
$296.56
|
| Rate for Payer: Mclaren Medicaid |
$49.13
|
| Rate for Payer: Mclaren Medicare |
$91.66
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$96.24
|
| Rate for Payer: Meridian Medicaid |
$51.59
|
| Rate for Payer: MI Amish Medical Board Commercial |
$105.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$280.08
|
| Rate for Payer: Nomi Health Commercial |
$270.20
|
| Rate for Payer: PACE Medicare |
$87.08
|
| Rate for Payer: PACE SWMI |
$91.66
|
| Rate for Payer: PHP Commercial |
$100.83
|
| Rate for Payer: PHP Medicaid |
$49.13
|
| Rate for Payer: PHP Medicare Advantage |
$91.66
|
| Rate for Payer: Priority Health Choice Medicaid |
$49.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$214.18
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$288.72
|
| Rate for Payer: Priority Health Medicare |
$91.66
|
| Rate for Payer: Priority Health Narrow Network |
$230.99
|
| Rate for Payer: Railroad Medicare Medicare |
$91.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$289.97
|
| Rate for Payer: UHC Dual Complete DSNP |
$91.66
|
| Rate for Payer: UHC Exchange |
$142.07
|
| Rate for Payer: UHC Medicare Advantage |
$91.66
|
| Rate for Payer: UHCCP DNSP |
$91.66
|
| Rate for Payer: UHCCP Medicaid |
$49.13
|
| Rate for Payer: VA VA |
$91.66
|
|
|
HC PV JAK2V617F
|
Facility
|
IP
|
$329.51
|
|
|
Service Code
|
CPT 81270
|
| Hospital Charge Code |
31000147
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$214.18 |
| Max. Negotiated Rate |
$329.51 |
| Rate for Payer: Aetna Commercial |
$296.56
|
| Rate for Payer: ASR ASR |
$319.62
|
| Rate for Payer: ASR Commercial |
$319.62
|
| Rate for Payer: BCBS Trust/PPO |
$268.52
|
| Rate for Payer: BCN Commercial |
$255.47
|
| Rate for Payer: Cash Price |
$263.61
|
| Rate for Payer: Cofinity Commercial |
$309.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$263.61
|
| Rate for Payer: Healthscope Commercial |
$329.51
|
| Rate for Payer: Healthscope Whirlpool |
$319.62
|
| Rate for Payer: Mclaren Commercial |
$296.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$280.08
|
| Rate for Payer: Nomi Health Commercial |
$270.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$214.18
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$289.97
|
|
|
HC PYRUVATE KINASE RBC
|
Facility
|
IP
|
$94.86
|
|
|
Service Code
|
CPT 84220
|
| Hospital Charge Code |
30100415
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$61.66 |
| Max. Negotiated Rate |
$94.86 |
| Rate for Payer: Aetna Commercial |
$85.37
|
| Rate for Payer: ASR ASR |
$92.01
|
| Rate for Payer: ASR Commercial |
$92.01
|
| Rate for Payer: BCBS Trust/PPO |
$77.30
|
| Rate for Payer: BCN Commercial |
$73.54
|
| Rate for Payer: Cash Price |
$75.89
|
| Rate for Payer: Cofinity Commercial |
$89.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$75.89
|
| Rate for Payer: Healthscope Commercial |
$94.86
|
| Rate for Payer: Healthscope Whirlpool |
$92.01
|
| Rate for Payer: Mclaren Commercial |
$85.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$80.63
|
| Rate for Payer: Nomi Health Commercial |
$77.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$61.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$83.48
|
|
|
HC PYRUVATE KINASE RBC
|
Facility
|
OP
|
$94.86
|
|
|
Service Code
|
CPT 84220
|
| Hospital Charge Code |
30100415
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$5.06 |
| Max. Negotiated Rate |
$94.86 |
| Rate for Payer: Aetna Commercial |
$85.37
|
| Rate for Payer: Aetna Medicare |
$9.44
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$11.80
|
| Rate for Payer: Amish Plain Church Group Commercial |
$11.80
|
| Rate for Payer: ASR ASR |
$92.01
|
| Rate for Payer: ASR Commercial |
$92.01
|
| Rate for Payer: BCBS Complete |
$5.31
|
| Rate for Payer: BCBS MAPPO |
$9.44
|
| Rate for Payer: BCBS Trust/PPO |
$77.68
|
| Rate for Payer: BCN Commercial |
$73.54
|
| Rate for Payer: BCN Medicare Advantage |
$9.44
|
| Rate for Payer: Cash Price |
$75.89
|
| Rate for Payer: Cash Price |
$75.89
|
| Rate for Payer: Cofinity Commercial |
$89.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$75.89
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$9.44
|
| Rate for Payer: Healthscope Commercial |
$94.86
|
| Rate for Payer: Healthscope Whirlpool |
$92.01
|
| Rate for Payer: Humana Choice PPO Medicare |
$9.44
|
| Rate for Payer: Mclaren Commercial |
$85.37
|
| Rate for Payer: Mclaren Medicaid |
$5.06
|
| Rate for Payer: Mclaren Medicare |
$9.44
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$9.91
|
| Rate for Payer: Meridian Medicaid |
$5.31
|
| Rate for Payer: MI Amish Medical Board Commercial |
$10.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$80.63
|
| Rate for Payer: Nomi Health Commercial |
$77.79
|
| Rate for Payer: PACE Medicare |
$8.97
|
| Rate for Payer: PACE SWMI |
$9.44
|
| Rate for Payer: PHP Commercial |
$10.38
|
| Rate for Payer: PHP Medicaid |
$5.06
|
| Rate for Payer: PHP Medicare Advantage |
$9.44
|
| Rate for Payer: Priority Health Choice Medicaid |
$5.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$61.66
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$83.12
|
| Rate for Payer: Priority Health Medicare |
$9.44
|
| Rate for Payer: Priority Health Narrow Network |
$66.50
|
| Rate for Payer: Railroad Medicare Medicare |
$9.44
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$83.48
|
| Rate for Payer: UHC Dual Complete DSNP |
$9.44
|
| Rate for Payer: UHC Exchange |
$14.63
|
| Rate for Payer: UHC Medicare Advantage |
$9.44
|
| Rate for Payer: UHCCP DNSP |
$9.44
|
| Rate for Payer: UHCCP Medicaid |
$5.06
|
| Rate for Payer: VA VA |
$9.44
|
|
|
HC PYRUVATE PYRUVIC ACID
|
Facility
|
IP
|
$52.02
|
|
|
Service Code
|
CPT 84210
|
| Hospital Charge Code |
30100414
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$33.81 |
| Max. Negotiated Rate |
$52.02 |
| Rate for Payer: Aetna Commercial |
$46.82
|
| Rate for Payer: ASR ASR |
$50.46
|
| Rate for Payer: ASR Commercial |
$50.46
|
| Rate for Payer: BCBS Trust/PPO |
$42.39
|
| Rate for Payer: BCN Commercial |
$40.33
|
| Rate for Payer: Cash Price |
$41.62
|
| Rate for Payer: Cofinity Commercial |
$48.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$41.62
|
| Rate for Payer: Healthscope Commercial |
$52.02
|
| Rate for Payer: Healthscope Whirlpool |
$50.46
|
| Rate for Payer: Mclaren Commercial |
$46.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$44.22
|
| Rate for Payer: Nomi Health Commercial |
$42.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$33.81
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$45.78
|
|
