|
PR REPAIR BLOOD VESSEL DIRECT INTRA-ABDOMINAL
|
Professional
|
Both
|
$5,052.00
|
|
|
Service Code
|
HCPCS 35221
|
| Min. Negotiated Rate |
$926.34 |
| Max. Negotiated Rate |
$3,283.80 |
| Rate for Payer: Aetna Commercial |
$1,976.34
|
| Rate for Payer: Aetna Medicare |
$2,526.00
|
| Rate for Payer: BCBS Complete |
$972.66
|
| Rate for Payer: BCBS Trust/PPO |
$1,367.77
|
| Rate for Payer: BCN Commercial |
$2,119.89
|
| Rate for Payer: Cash Price |
$4,041.60
|
| Rate for Payer: Cash Price |
$4,041.60
|
| Rate for Payer: Meridian Medicaid |
$972.66
|
| Rate for Payer: Priority Health Choice Medicaid |
$926.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,283.80
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2,313.97
|
| Rate for Payer: Priority Health Narrow Network |
$2,313.97
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1,869.80
|
| Rate for Payer: UHC Exchange |
$1,869.80
|
| Rate for Payer: UHCCP Medicaid |
$926.34
|
|
|
PR REPAIR BLOOD VESSEL DIRECT LOWER EXTREMITY
|
Professional
|
Both
|
$2,660.00
|
|
|
Service Code
|
HCPCS 35226
|
| Min. Negotiated Rate |
$519.51 |
| Max. Negotiated Rate |
$2,526.86 |
| Rate for Payer: Aetna Commercial |
$1,116.75
|
| Rate for Payer: Aetna Medicare |
$1,330.00
|
| Rate for Payer: BCBS Complete |
$545.49
|
| Rate for Payer: BCBS Trust/PPO |
$2,526.86
|
| Rate for Payer: BCN Commercial |
$1,190.91
|
| Rate for Payer: Cash Price |
$2,128.00
|
| Rate for Payer: Cash Price |
$2,128.00
|
| Rate for Payer: Meridian Medicaid |
$545.49
|
| Rate for Payer: Priority Health Choice Medicaid |
$519.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,729.00
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,294.99
|
| Rate for Payer: Priority Health Narrow Network |
$1,294.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1,121.35
|
| Rate for Payer: UHC Exchange |
$1,121.35
|
| Rate for Payer: UHCCP Medicaid |
$519.51
|
|
|
PR REPAIR BLOOD VESSEL DIRECT NECK
|
Professional
|
Both
|
$4,240.00
|
|
|
Service Code
|
HCPCS 35201
|
| Min. Negotiated Rate |
$584.05 |
| Max. Negotiated Rate |
$2,756.00 |
| Rate for Payer: Aetna Commercial |
$1,265.63
|
| Rate for Payer: Aetna Medicare |
$2,120.00
|
| Rate for Payer: BCBS Complete |
$613.25
|
| Rate for Payer: BCBS Trust/PPO |
$871.17
|
| Rate for Payer: BCN Commercial |
$1,340.94
|
| Rate for Payer: Cash Price |
$3,392.00
|
| Rate for Payer: Cash Price |
$3,392.00
|
| Rate for Payer: Meridian Medicaid |
$613.25
|
| Rate for Payer: Priority Health Choice Medicaid |
$584.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,756.00
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,463.58
|
| Rate for Payer: Priority Health Narrow Network |
$1,463.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1,241.78
|
| Rate for Payer: UHC Exchange |
$1,241.78
|
| Rate for Payer: UHCCP Medicaid |
$584.05
|
|
|
PR REPAIR BLOOD VESSEL DIRECT UPPER EXTREMITY
|
Professional
|
Both
|
$2,790.00
|
|
|
Service Code
|
HCPCS 35206
|
| Min. Negotiated Rate |
$503.53 |
| Max. Negotiated Rate |
$1,959.46 |
| Rate for Payer: Aetna Commercial |
$1,048.65
|
| Rate for Payer: Aetna Medicare |
$1,395.00
|
| Rate for Payer: BCBS Complete |
$528.71
|
| Rate for Payer: BCBS Trust/PPO |
$1,959.46
|
| Rate for Payer: BCN Commercial |
$1,129.33
|
| Rate for Payer: Cash Price |
$2,232.00
|
| Rate for Payer: Cash Price |
$2,232.00
|
| Rate for Payer: Meridian Medicaid |
$528.71
|
| Rate for Payer: Priority Health Choice Medicaid |
$503.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,813.50
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,243.40
|
| Rate for Payer: Priority Health Narrow Network |
$1,243.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1,015.81
|
| Rate for Payer: UHC Exchange |
$1,015.81
|
| Rate for Payer: UHCCP Medicaid |
$503.53
|
|
|
PR REPAIR BLOOD VESSEL VEIN GRAFT INTRA-ABDOMINAL
|
Professional
|
Both
|
$3,839.00
|
|
|
Service Code
|
HCPCS 35251
|
| Min. Negotiated Rate |
$808.30 |
| Max. Negotiated Rate |
$2,725.59 |
| Rate for Payer: Aetna Commercial |
$2,327.60
|
| Rate for Payer: Aetna Medicare |
$1,919.50
|
| Rate for Payer: BCBS Complete |
$1,141.74
|
| Rate for Payer: BCBS Trust/PPO |
$808.30
|
| Rate for Payer: BCN Commercial |
$2,514.24
|
| Rate for Payer: Cash Price |
$3,071.20
|
| Rate for Payer: Cash Price |
$3,071.20
|
| Rate for Payer: Meridian Medicaid |
$1,141.74
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,087.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,495.35
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2,725.59
|
| Rate for Payer: Priority Health Narrow Network |
$2,725.59
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2,220.84
|
| Rate for Payer: UHC Exchange |
$2,220.84
|
| Rate for Payer: UHCCP Medicaid |
$1,087.37
|
|
|
PR REPAIR BLOOD VESSEL VEIN GRAFT LOWER EXTREMITY
|
Professional
|
Both
|
$4,575.00
|
|
|
Service Code
|
HCPCS 35256
|
| Min. Negotiated Rate |
$639.43 |
| Max. Negotiated Rate |
$2,973.75 |
| Rate for Payer: Aetna Commercial |
$1,380.04
|
| Rate for Payer: Aetna Medicare |
$2,287.50
|
| Rate for Payer: BCBS Complete |
$671.40
|
| Rate for Payer: BCBS Trust/PPO |
$1,015.92
|
| Rate for Payer: BCN Commercial |
$1,459.19
|
| Rate for Payer: Cash Price |
$3,660.00
|
| Rate for Payer: Cash Price |
$3,660.00
|
| Rate for Payer: Meridian Medicaid |
$671.40
|
| Rate for Payer: Priority Health Choice Medicaid |
$639.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,973.75
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,578.99
|
| Rate for Payer: Priority Health Narrow Network |
$1,578.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1,367.23
|
| Rate for Payer: UHC Exchange |
$1,367.23
|
| Rate for Payer: UHCCP Medicaid |
$639.43
|
|
|
PR REPAIR BLOOD VESSEL W/GRAFT OTHER/THAN VEIN NECK
|
Professional
|
Both
|
$4,692.00
|
|
|
Service Code
|
HCPCS 35261
|
| Min. Negotiated Rate |
$615.36 |
| Max. Negotiated Rate |
$3,049.80 |
| Rate for Payer: Aetna Commercial |
$1,315.04
|
| Rate for Payer: Aetna Medicare |
$2,346.00
|
| Rate for Payer: BCBS Complete |
$646.13
|
| Rate for Payer: BCBS Trust/PPO |
$773.96
|
| Rate for Payer: BCN Commercial |
$1,398.59
|
| Rate for Payer: Cash Price |
$3,753.60
|
| Rate for Payer: Cash Price |
$3,753.60
|
| Rate for Payer: Meridian Medicaid |
$646.13
|
| Rate for Payer: Priority Health Choice Medicaid |
$615.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,049.80
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,531.13
|
| Rate for Payer: Priority Health Narrow Network |
$1,531.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1,396.16
|
| Rate for Payer: UHC Exchange |
$1,396.16
|
| Rate for Payer: UHCCP Medicaid |
$615.36
|
|
|
PR REPAIR BLOOD VESSEL W/VEIN GRAFT NECK
|
Professional
|
Both
|
$1,896.00
|
|
|
Service Code
|
HCPCS 35231
|
| Min. Negotiated Rate |
$794.92 |
| Max. Negotiated Rate |
$2,591.31 |
| Rate for Payer: Aetna Commercial |
$1,673.50
|
| Rate for Payer: Aetna Medicare |
$948.00
|
| Rate for Payer: BCBS Complete |
$834.67
|
| Rate for Payer: BCBS Trust/PPO |
$2,591.31
|
| Rate for Payer: BCN Commercial |
$1,810.06
|
| Rate for Payer: Cash Price |
$1,516.80
|
| Rate for Payer: Cash Price |
$1,516.80
|
| Rate for Payer: Meridian Medicaid |
$834.67
|
| Rate for Payer: Priority Health Choice Medicaid |
$794.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,232.40
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,969.88
|
| Rate for Payer: Priority Health Narrow Network |
$1,969.88
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1,544.83
|
| Rate for Payer: UHC Exchange |
$1,544.83
|
| Rate for Payer: UHCCP Medicaid |
$794.92
|
|
|
PR REPAIR BLOOD VESSEL W/VEIN GRAFT UPPER EXTREMITY
|
Professional
|
Both
|
$3,698.00
|
|
|
Service Code
|
HCPCS 35236
|
| Min. Negotiated Rate |
$636.02 |
| Max. Negotiated Rate |
$2,563.84 |
| Rate for Payer: Aetna Commercial |
$1,348.22
|
| Rate for Payer: Aetna Medicare |
$1,849.00
|
| Rate for Payer: BCBS Complete |
$667.82
|
| Rate for Payer: BCBS Trust/PPO |
$2,563.84
|
| Rate for Payer: BCN Commercial |
$1,427.91
|
| Rate for Payer: Cash Price |
$2,958.40
|
| Rate for Payer: Cash Price |
$2,958.40
|
| Rate for Payer: Meridian Medicaid |
$667.82
|
| Rate for Payer: Priority Health Choice Medicaid |
$636.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,403.70
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,565.69
|
| Rate for Payer: Priority Health Narrow Network |
$1,565.69
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1,299.61
|
| Rate for Payer: UHC Exchange |
$1,299.61
|
| Rate for Payer: UHCCP Medicaid |
$636.02
|
|
|
PR REPAIR BROW PTOSIS
|
Professional
|
Both
|
$1,326.00
|
|
|
Service Code
|
HCPCS 67900
|
| Min. Negotiated Rate |
$183.32 |
| Max. Negotiated Rate |
$944.61 |
| Rate for Payer: Aetna Commercial |
$658.86
|
| Rate for Payer: Aetna Medicare |
$663.00
|
| Rate for Payer: BCBS Complete |
$336.60
|
| Rate for Payer: BCBS Trust/PPO |
$183.32
|
| Rate for Payer: BCN Commercial |
$944.61
|
| Rate for Payer: Cash Price |
$1,060.80
|
| Rate for Payer: Cash Price |
$1,060.80
|
| Rate for Payer: Meridian Medicaid |
$336.60
|
| Rate for Payer: Priority Health Choice Medicaid |
$320.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$861.90
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$878.53
|
| Rate for Payer: Priority Health Narrow Network |
$878.53
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$548.35
|
| Rate for Payer: UHC Exchange |
$548.35
|
| Rate for Payer: UHCCP Medicaid |
$320.57
|
|
|
PR REPAIR CARDIAC WOUND W/CARDIOPULMONARY BYPASS
|
Professional
|
Both
|
$7,686.00
|
|
|
Service Code
|
HCPCS 33305
|
| Min. Negotiated Rate |
$786.64 |
| Max. Negotiated Rate |
$6,391.47 |
| Rate for Payer: Aetna Commercial |
$5,503.81
|
| Rate for Payer: Aetna Medicare |
$3,843.00
|
| Rate for Payer: BCBS Complete |
$2,688.94
|
| Rate for Payer: BCBS Trust/PPO |
$786.64
|
| Rate for Payer: BCN Commercial |
$5,839.21
|
| Rate for Payer: Cash Price |
$6,148.80
|
| Rate for Payer: Cash Price |
$6,148.80
|
| Rate for Payer: Meridian Medicaid |
$2,688.94
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,560.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4,995.90
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$6,391.47
|
| Rate for Payer: Priority Health Narrow Network |
$6,391.47
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$5,307.99
|
| Rate for Payer: UHC Exchange |
$5,307.99
|
| Rate for Payer: UHCCP Medicaid |
$2,560.90
|
|
|
PR REPAIR CARDIAC WOUND W/O BYPASS
|
Professional
|
Both
|
$4,597.00
|
|
|
Service Code
|
HCPCS 33300
|
| Min. Negotiated Rate |
$1,537.22 |
| Max. Negotiated Rate |
$3,818.50 |
| Rate for Payer: Aetna Commercial |
$3,287.49
|
| Rate for Payer: Aetna Medicare |
$2,298.50
|
| Rate for Payer: BCBS Complete |
$1,614.08
|
| Rate for Payer: BCBS Trust/PPO |
$2,283.84
|
| Rate for Payer: BCN Commercial |
$3,485.73
|
| Rate for Payer: Cash Price |
$3,677.60
|
| Rate for Payer: Cash Price |
$3,677.60
|
| Rate for Payer: Meridian Medicaid |
$1,614.08
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,537.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,988.05
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$3,818.50
|
| Rate for Payer: Priority Health Narrow Network |
$3,818.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3,148.06
|
| Rate for Payer: UHC Exchange |
$3,148.06
|
| Rate for Payer: UHCCP Medicaid |
$1,537.22
|
|
|
PR REPAIR CHOANAL ATRESIA INTRANASAL
|
Professional
|
Both
|
$1,227.00
|
|
|
Service Code
|
HCPCS 30540
|
| Min. Negotiated Rate |
$472.43 |
| Max. Negotiated Rate |
$1,096.60 |
| Rate for Payer: Aetna Commercial |
$932.51
|
| Rate for Payer: Aetna Medicare |
$613.50
|
| Rate for Payer: BCBS Complete |
$496.05
|
| Rate for Payer: BCBS Trust/PPO |
$614.94
|
| Rate for Payer: BCN Commercial |
$1,096.60
|
| Rate for Payer: Cash Price |
$981.60
|
| Rate for Payer: Cash Price |
$981.60
|
| Rate for Payer: Meridian Medicaid |
$496.05
|
| Rate for Payer: Priority Health Choice Medicaid |
$472.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$797.55
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,036.31
|
| Rate for Payer: Priority Health Narrow Network |
$1,036.31
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$732.11
|
| Rate for Payer: UHC Exchange |
$732.11
|
| Rate for Payer: UHCCP Medicaid |
$472.43
|
|
|
PR REPAIR COMPLEX EYELID/NOSE/EAR/LIP 1.1-2.5 CM
|
Professional
|
Both
|
$928.00
|
|
|
Service Code
|
HCPCS 13151
|
| Min. Negotiated Rate |
$177.86 |
| Max. Negotiated Rate |
$1,139.30 |
| Rate for Payer: Aetna Commercial |
$299.73
|
| Rate for Payer: Aetna Medicare |
$464.00
|
| Rate for Payer: BCBS Complete |
$186.75
|
| Rate for Payer: BCBS Trust/PPO |
$1,139.30
|
| Rate for Payer: BCN Commercial |
$622.09
|
| Rate for Payer: Cash Price |
$742.40
|
| Rate for Payer: Cash Price |
$742.40
|
| Rate for Payer: Meridian Medicaid |
$186.75
|
| Rate for Payer: Priority Health Choice Medicaid |
$177.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$603.20
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$373.86
|
| Rate for Payer: Priority Health Narrow Network |
$373.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$337.08
|
| Rate for Payer: UHC Exchange |
$337.08
|
| Rate for Payer: UHCCP Medicaid |
$177.86
|
|
|
PR REPAIR COMPLEX EYELID/NOSE/EAR/LIP 2.6-7.5 CM
|
Professional
|
Both
|
$1,232.00
|
|
|
Service Code
|
HCPCS 13152
|
| Min. Negotiated Rate |
$213.64 |
| Max. Negotiated Rate |
$2,272.50 |
| Rate for Payer: Aetna Commercial |
$361.80
|
| Rate for Payer: Aetna Medicare |
$616.00
|
| Rate for Payer: BCBS Complete |
$224.32
|
| Rate for Payer: BCBS Trust/PPO |
$2,272.50
|
| Rate for Payer: BCN Commercial |
$729.10
|
| Rate for Payer: Cash Price |
$985.60
|
| Rate for Payer: Cash Price |
$985.60
|
| Rate for Payer: Meridian Medicaid |
$224.32
|
| Rate for Payer: Priority Health Choice Medicaid |
$213.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$800.80
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$450.61
|
| Rate for Payer: Priority Health Narrow Network |
$450.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$455.33
|
| Rate for Payer: UHC Exchange |
$455.33
|
| Rate for Payer: UHCCP Medicaid |
$213.64
|
|
|
PR REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 1.1-2.5 CM
|
Professional
|
Both
|
$605.00
|
|
|
Service Code
|
HCPCS 13131
|
| Min. Negotiated Rate |
$5.64 |
| Max. Negotiated Rate |
$570.29 |
| Rate for Payer: Aetna Commercial |
$260.73
|
| Rate for Payer: Aetna Medicare |
$302.50
|
| Rate for Payer: BCBS Complete |
$162.81
|
| Rate for Payer: BCBS Trust/PPO |
$5.64
|
| Rate for Payer: BCN Commercial |
$570.29
|
| Rate for Payer: Cash Price |
$484.00
|
| Rate for Payer: Cash Price |
$484.00
|
| Rate for Payer: Meridian Medicaid |
$162.81
|
| Rate for Payer: Priority Health Choice Medicaid |
$155.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$393.25
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$325.54
|
| Rate for Payer: Priority Health Narrow Network |
$325.54
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$292.07
|
| Rate for Payer: UHC Exchange |
$292.07
|
| Rate for Payer: UHCCP Medicaid |
$155.06
|
|
|
PR REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 2.6-7.5 CM
|
Professional
|
Both
|
$1,306.00
|
|
|
Service Code
|
HCPCS 13132
|
| Min. Negotiated Rate |
$192.98 |
| Max. Negotiated Rate |
$848.90 |
| Rate for Payer: Aetna Commercial |
$324.96
|
| Rate for Payer: Aetna Medicare |
$653.00
|
| Rate for Payer: BCBS Complete |
$202.63
|
| Rate for Payer: BCBS Trust/PPO |
$349.63
|
| Rate for Payer: BCN Commercial |
$691.96
|
| Rate for Payer: Cash Price |
$1,044.80
|
| Rate for Payer: Cash Price |
$1,044.80
|
| Rate for Payer: Meridian Medicaid |
$202.63
|
| Rate for Payer: Priority Health Choice Medicaid |
$192.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$848.90
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$406.37
|
| Rate for Payer: Priority Health Narrow Network |
$406.37
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$497.90
|
| Rate for Payer: UHC Exchange |
$497.90
|
| Rate for Payer: UHCCP Medicaid |
$192.98
|
|
|
PR REPAIR COMPLEX F/C/C/M/N/AX/G/H/F EA ADDL 5 CM/<
|
Professional
|
Both
|
$408.00
|
|
|
Service Code
|
HCPCS 13133
|
| Min. Negotiated Rate |
$79.45 |
| Max. Negotiated Rate |
$1,316.25 |
| Rate for Payer: Aetna Commercial |
$136.49
|
| Rate for Payer: Aetna Medicare |
$204.00
|
| Rate for Payer: BCBS Complete |
$83.42
|
| Rate for Payer: BCBS Trust/PPO |
$1,316.25
|
| Rate for Payer: BCN Commercial |
$245.80
|
| Rate for Payer: Cash Price |
$326.40
|
| Rate for Payer: Cash Price |
$326.40
|
| Rate for Payer: Meridian Medicaid |
$83.42
|
| Rate for Payer: Priority Health Choice Medicaid |
$79.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$265.20
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$167.96
|
| Rate for Payer: Priority Health Narrow Network |
$167.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$143.12
|
| Rate for Payer: UHC Exchange |
$143.12
|
| Rate for Payer: UHCCP Medicaid |
$79.45
|
|
|
PR REPAIR COMPLEX SCALP/ARM/LEG 1.1-2.5 CM
|
Professional
|
Both
|
$547.00
|
|
|
Service Code
|
HCPCS 13120
|
| Min. Negotiated Rate |
$84.02 |
| Max. Negotiated Rate |
$522.88 |
| Rate for Payer: Aetna Commercial |
$250.47
|
| Rate for Payer: Aetna Medicare |
$273.50
|
| Rate for Payer: BCBS Complete |
$154.99
|
| Rate for Payer: BCBS Trust/PPO |
$84.02
|
| Rate for Payer: BCN Commercial |
$522.88
|
| Rate for Payer: Cash Price |
$437.60
|
| Rate for Payer: Cash Price |
$437.60
|
| Rate for Payer: Meridian Medicaid |
$154.99
|
| Rate for Payer: Priority Health Choice Medicaid |
$147.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$355.55
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$312.00
|
| Rate for Payer: Priority Health Narrow Network |
$312.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$258.31
|
| Rate for Payer: UHC Exchange |
$258.31
|
| Rate for Payer: UHCCP Medicaid |
$147.61
|
|
|
PR REPAIR COMPLEX SCALP/ARM/LEG 2.6-7.5 CM
|
Professional
|
Both
|
$898.00
|
|
|
Service Code
|
HCPCS 13121
|
| Hospital Charge Code |
13121
|
| Min. Negotiated Rate |
$165.08 |
| Max. Negotiated Rate |
$624.53 |
| Rate for Payer: Aetna Commercial |
$277.38
|
| Rate for Payer: Aetna Medicare |
$449.00
|
| Rate for Payer: BCBS Complete |
$173.33
|
| Rate for Payer: BCBS Trust/PPO |
$347.82
|
| Rate for Payer: BCN Commercial |
$624.53
|
| Rate for Payer: Cash Price |
$718.40
|
| Rate for Payer: Cash Price |
$718.40
|
| Rate for Payer: Meridian Medicaid |
$173.33
|
| Rate for Payer: Priority Health Choice Medicaid |
$165.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$583.70
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$346.77
|
| Rate for Payer: Priority Health Narrow Network |
$346.77
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$344.00
|
| Rate for Payer: UHC Exchange |
$344.00
|
| Rate for Payer: UHCCP Medicaid |
$165.08
|
|
|
PR REPAIR COMPLEX SCALP/ARM/LEG 2.6-7.5 CM
|
Facility
|
IP
|
$898.00
|
|
|
Service Code
|
CPT 13121
|
| Hospital Charge Code |
13121
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$583.70 |
| Max. Negotiated Rate |
$898.00 |
| Rate for Payer: Aetna Commercial |
$808.20
|
| Rate for Payer: ASR ASR |
$871.06
|
| Rate for Payer: ASR Commercial |
$871.06
|
| Rate for Payer: BCBS Trust/PPO |
$731.78
|
| Rate for Payer: BCN Commercial |
$696.22
|
| Rate for Payer: Cash Price |
$718.40
|
| Rate for Payer: Cofinity Commercial |
$844.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$718.40
|
| Rate for Payer: Healthscope Commercial |
$898.00
|
| Rate for Payer: Healthscope Whirlpool |
$871.06
|
| Rate for Payer: Mclaren Commercial |
$808.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$763.30
|
| Rate for Payer: Nomi Health Commercial |
$736.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$583.70
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$790.24
|
|
|
PR REPAIR COMPLEX SCALP/ARM/LEG 2.6-7.5 CM
|
Professional
|
Both
|
$898.00
|
|
|
Service Code
|
HCPCS 13121
|
| Min. Negotiated Rate |
$165.08 |
| Max. Negotiated Rate |
$624.53 |
| Rate for Payer: Aetna Commercial |
$277.38
|
| Rate for Payer: Aetna Medicare |
$449.00
|
| Rate for Payer: BCBS Complete |
$173.33
|
| Rate for Payer: BCBS Trust/PPO |
$347.82
|
| Rate for Payer: BCN Commercial |
$624.53
|
| Rate for Payer: Cash Price |
$718.40
|
| Rate for Payer: Cash Price |
$718.40
|
| Rate for Payer: Meridian Medicaid |
$173.33
|
| Rate for Payer: Priority Health Choice Medicaid |
$165.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$583.70
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$346.77
|
| Rate for Payer: Priority Health Narrow Network |
$346.77
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$344.00
|
| Rate for Payer: UHC Exchange |
$344.00
|
| Rate for Payer: UHCCP Medicaid |
$165.08
|
|
|
PR REPAIR COMPLEX SCALP/ARM/LEG 2.6-7.5 CM
|
Facility
|
OP
|
$898.00
|
|
|
Service Code
|
CPT 13121
|
| Hospital Charge Code |
13121
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$321.47 |
| Max. Negotiated Rate |
$929.61 |
| Rate for Payer: Aetna Commercial |
$808.20
|
| Rate for Payer: Aetna Medicare |
$599.75
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$749.69
|
| Rate for Payer: Amish Plain Church Group Commercial |
$749.69
|
| Rate for Payer: ASR ASR |
$871.06
|
| Rate for Payer: ASR Commercial |
$871.06
|
| Rate for Payer: BCBS Complete |
$337.54
|
| Rate for Payer: BCBS MAPPO |
$599.75
|
| Rate for Payer: BCBS Trust/PPO |
$735.37
|
| Rate for Payer: BCN Commercial |
$696.22
|
| Rate for Payer: BCN Medicare Advantage |
$599.75
|
| Rate for Payer: Cash Price |
$718.40
|
| Rate for Payer: Cash Price |
$718.40
|
| Rate for Payer: Cofinity Commercial |
$844.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$718.40
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$599.75
|
| Rate for Payer: Healthscope Commercial |
$898.00
|
| Rate for Payer: Healthscope Whirlpool |
$871.06
|
| Rate for Payer: Humana Choice PPO Medicare |
$599.75
|
| Rate for Payer: Mclaren Commercial |
$808.20
|
| Rate for Payer: Mclaren Medicaid |
$321.47
|
| Rate for Payer: Mclaren Medicare |
$599.75
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$629.74
|
| Rate for Payer: Meridian Medicaid |
$337.54
|
| Rate for Payer: MI Amish Medical Board Commercial |
$689.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$763.30
|
| Rate for Payer: Nomi Health Commercial |
$736.36
|
| Rate for Payer: PACE Medicare |
$569.76
|
| Rate for Payer: PACE SWMI |
$599.75
|
| Rate for Payer: PHP Commercial |
$659.72
|
| Rate for Payer: PHP Medicaid |
$321.47
|
| Rate for Payer: PHP Medicare Advantage |
$599.75
|
| Rate for Payer: Priority Health Choice Medicaid |
$321.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$583.70
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$478.73
|
| Rate for Payer: Priority Health Medicare |
$599.75
|
| Rate for Payer: Priority Health Narrow Network |
$382.98
|
| Rate for Payer: Railroad Medicare Medicare |
$599.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$790.24
|
| Rate for Payer: UHC Dual Complete DSNP |
$599.75
|
| Rate for Payer: UHC Exchange |
$929.61
|
| Rate for Payer: UHC Medicare Advantage |
$599.75
|
| Rate for Payer: UHCCP DNSP |
$599.75
|
| Rate for Payer: UHCCP Medicaid |
$321.47
|
| Rate for Payer: VA VA |
$599.75
|
|
|
PR REPAIR COMPLEX SCALP/ARM/LEG EA ADDL 5 CM/<
|
Facility
|
OP
|
$281.00
|
|
|
Service Code
|
CPT 13122
|
| Hospital Charge Code |
13122
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$112.40 |
| Max. Negotiated Rate |
$281.00 |
| Rate for Payer: Aetna Commercial |
$252.90
|
| Rate for Payer: Aetna Medicare |
$140.50
|
| Rate for Payer: ASR ASR |
$272.57
|
| Rate for Payer: ASR Commercial |
$272.57
|
| Rate for Payer: BCBS Complete |
$112.40
|
| Rate for Payer: BCBS Trust/PPO |
$230.11
|
| Rate for Payer: BCN Commercial |
$217.86
|
| Rate for Payer: Cash Price |
$224.80
|
| Rate for Payer: Cash Price |
$224.80
|
| Rate for Payer: Cofinity Commercial |
$264.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$224.80
|
| Rate for Payer: Healthscope Commercial |
$281.00
|
| Rate for Payer: Healthscope Whirlpool |
$272.57
|
| Rate for Payer: Mclaren Commercial |
$252.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$238.85
|
| Rate for Payer: Nomi Health Commercial |
$230.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$182.65
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$265.98
|
| Rate for Payer: Priority Health Narrow Network |
$212.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$247.28
|
|
|
PR REPAIR COMPLEX SCALP/ARM/LEG EA ADDL 5 CM/<
|
Facility
|
IP
|
$281.00
|
|
|
Service Code
|
CPT 13122
|
| Hospital Charge Code |
13122
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$182.65 |
| Max. Negotiated Rate |
$281.00 |
| Rate for Payer: Aetna Commercial |
$252.90
|
| Rate for Payer: ASR ASR |
$272.57
|
| Rate for Payer: ASR Commercial |
$272.57
|
| Rate for Payer: BCBS Trust/PPO |
$228.99
|
| Rate for Payer: BCN Commercial |
$217.86
|
| Rate for Payer: Cash Price |
$224.80
|
| Rate for Payer: Cofinity Commercial |
$264.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$224.80
|
| Rate for Payer: Healthscope Commercial |
$281.00
|
| Rate for Payer: Healthscope Whirlpool |
$272.57
|
| Rate for Payer: Mclaren Commercial |
$252.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$238.85
|
| Rate for Payer: Nomi Health Commercial |
$230.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$182.65
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$247.28
|
|
